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Differential  Diagnosis 


PRESENTED    THROUGH 
AN  ANALYSIS  OF  385  CASES 


By 


RICHARD   C.   CABOT,  M.D. 

ASSISTANT     PROFESSOR    OF    CLINICAL    MKDICINK,    HARVARD    UNIVERSITY    MEDICAL    SCHOCTL,    BOSTON 


SECOND  EDITION,  REVISED 
PROEUSEL  V     ILL  USTRA  TED 


I'HII.ADKI.IMIIA     AM)     r.ONDON 


W.  B.  SAUNDERS    COMPANY 

191  2 


Copyright,  igii    by  W.   1!.   Saunders  Company.      Reprinted   March,   1911,  June,   1911,  and  October,   1911. 
Revised,  reprinted,  and  recopyrighted,  February,  1912. 

Copyright,  1912,  by  W.  H.  Saunders  Company 

Reprinted  October,  1912 


PSINTED     IN     AMERICA 

PRFSS     OF 
B.      SAUNDERS     COMPANY 
PHILAOtLPHIA 


PREFACE  TO  THE  SECOND  EDITION 


I  HAVE  corrected  some  typographical  errors  kindly  pointed  out  by 
correspondents,  reorganized  the  index  and  table  of  contents,  and 
made  a  few  more  material  changes.  Two  new  cases  are  introduced: 
one  by  the  kind  permission  of  Dr.  Frederick  J.  Bowen  of  Mount 
Morris,  N.  Y.,  whom  I  take  this  opportunity  of  thanking. 

Some  of  the  symptoms  not  treated  in  this  volume  ie.  g.,  hema- 
turia, edema,  diarrhea,  dyspepsia,  glandular  enlargement,  etc.)  will 
be  dealt  with  in  a  second  volume  along  the  same  lines. 


PREFACE 


The  attempt  to  make  and  defend  a  differential  diagnosis  brings 
all  one's  failings  into  sharp  relief.  Though  I  ha\e  done  my  Ijest  to 
avoid  obvious  errors  in  this  book,  I  am  confident  that  it  contains 
much  that  deserves — and  I  hope  will  recei\e — challenge  from  other 
physicians. 

My  lx;st  thanks  are  due  to  Dr.  James  H.  Young  for  help  in  the 
diagrams,  and  to  my  secretary,  ]Miss  Edith  K.  Richie,  who  has  made 
the  index  and  rendered  many  invaluable  services  throughout  the 
preparation  of  the  book. 

190  Marlborouc.h  St.,  Boston,  Mass. 


TABLE  OF  CONTENTS 


INTRODUCTION  Page 

The  Presenting  Symptom 17 

The  Grouping  of  Reasonable  Possibilities 17 

Advantages  of  the  Plan  Here  Adopted 18 

Limits 19 

Vulnerability  of  All  Differential  Diagnosis 19 

Omissions 21 

Explanation  of  Diagrams  and  Charts 22 

CHAPTER   I 

PAIN 

General  Considerations 24 

Degree  of  Pain 25 

Types  of  Pain 26 

Relation  of  Pain  to  Other  Facts 27 

Habit  Pains 29 

Theories  Regarding  the  Production  of  Pain 29 

CHAPTER  II 

HEADACHE 

General  Considerations 32 

Position  and  Nature  of  the  Headache 37 

Two  Traditional  Fallacies  About  Headache 38 

Important  Tests 39 

Case  \o. 

1.  Mc'thcmofilobinemia 39 

2.  Syphilitic   Periostitis 41 

3.  Syphilis 43 

4.  SN-jjhilis 45 

5.  Headache  of  Psyciiic  Origin 47 

6.  Uremic  Ileadaciie;  Chronic  (ilomeriiionephritis;  Graves'  Disease 49 

7.  Typhoid    I''e\er 5- 

8.  I'Vacture  of  the    iiase  of  Skull 54 

Q.  Sinusitis 55 

10.  Miliary  Tuberculosis 5O 

1 1.  Stone  in   the   Ki(liie\-  with   Abscess  and   Xe])hritis 5S 

I  2.  Malaria '10 

13.  i*arox>snial  Tai  hycardia  Coniplii  atin^  a  Chronic  M_\-ocardial  Insul'licii-m  \' .  M 

14.  Postpneumonic    luiipNcma (\^ 


6  TABLE    OF    CONTENTS 

Case  No.  Page 

15.  Staphylococcus  Infection  (Osteomyelitisj 65 

16.  Dementia  Paralytica 67 

17.  Headache  of  Unknown  Origin 68 

18.  Meningitis 69 

19.  Sinusitis 71 

20.  Typhoid   Fever 73 

21.  Miliary  Tuberculosis 74 

22.  Cerebral  Hemorrhage 76 

CHAPTER  III 

LUMBAR   PAIN 

Examination  of  Patients  with  Lumbar  Pain 87 

Case  \o. 

23.  Tuberculous  Pneumothorax 87 

24.  Hypertrophic  Spinal  Arthritis 89 

25.  Typhoid  Fever 91 

26.  Appendicitis;  Herpes  Zoster 93 

27.  Unknown  Infection 95 

28.  Sacro-iliac   Strain 96 

29.  Sacro-iliac   Strain 97 

30.  Renal  Infection,  Hematogenous  or  Ascending 98 

31.  Pneumonia 100 

32.  Debility loi 

33.  Typhoid  and  Colon  Bacillus  Infection 103 

34.  Neuritis 105 

35.  Infectious  Spondylitis 107 

36.  Vertebral  Tuberculosis 108 

37.  Aortic  Aneurysm 109 

38.  Lumbago  (?);  Infectious  Spondylitis  (?) no 

39.  Renal   Stone;   Multiple  Renal  Abscess in 

40.  (iall-stones 113 

41.  Rctro[)eril()neal  Sarcoma 114 

42.  Typhoidal  Spondylitis 115 

43.  Si)inal  Tuberculosis 117 

44.  Old  Syjjhilis;  Acute  Spondylitis 118 

45.  Renal  Stone 119 

46.  Debility 1 20 

47.  Streptocoi (US  Meningitis 121 

48.  Prolapsed,  Retroverted,  Incarcerated,  Pregnant  Uterus 122 

49.  Parturition 1 23 

49(i.  Tetanus 1 24 

CHAPTER   IV 

GEXKRAL   ABDOMINAL   PAIN 

Cask  Xo. 

50.  Neurosis;  Mucous  Colitis 128 

51.  Had  Hygiene 132 

52.  Constipation 133 

53.  Peritoneal   Tuberculosis 134 

54.  P')>toperali\e  Neurosis 136 


TABLE    OF    CONTENTS  7 

Case  No.  Page 

55.  Typhoid  Fever 137 

56.  Neurosis 139 

57.  Lead  Poisoning 140 

58.  Dynamic  Aorta 141 

59.  Acute  Gastro-enteritis 143 

60.  Cancer  of  the  Stomach 144 

6r.  Recurrent  Intestinal  Cancer 146 

62.  Tertian  Malaria 148 

63.  Perforative  Colitis  and  General  Peritonitis .' 149 

64.  Cancer  of  the  Rectum 1 50 

65.  Obstruction  of  the  Intestine;  Volvulus 151 

CHAPTER   V 

EPIGASTRIC   PAIN 
Case  N'o. 

66.  Hepatic  Gumma;  Syphilis 154 

67.  Piumbism 157 

68.  Constipation 159 

6q.  Chlorosis 160 

70.  Tabes  Dorsalis 161 

71.  Gastric  Neurosis 162 

72.  Duodenal  Ulcer 163 

73.  Ciall-stones 165 

74.  Hyperchlorhydria  (.\lcoholism  ?) 167 

75.  .\ngina  Pectoris  (Low) 168 

76.  Piumbism 169 

77.  Sarcoma  Testis  with  Metastases 171 

78.  Tuberculous  Peritonitis 172 

79.  Constipation 173 

80.  Pyloric  .Vdhesions 174 

81.  Cholelithiasis  and  Gangrenous  Gall-bladder 176 

82.  Cholelithiasis  with  Perforations 178 

83.  Acute  Pericarditis 1 79 

84.  .Vrteriosclerosis;  X'ascular  Crises 181 

85.  Pericarditis 183 

86.  Gastric  Cancer 1 84 

87.  Pancreatic  Cancer  (Chronic   Pancreatitis  ?) 1S6 

88.  Gastric  Ulcer 1S7 

8g.  Gastric  Neurosis iSq 

go.  (iastric  Neurosis 100 

Qi.  .Mroholism 102 

1)2.   Mt'lancholia 103 

03.   He|)atic  Congestion   (Uncompensated  X'ahular  Heart  Disease) 105 

()4.  (iall-stones uj; 

()5.   Gall-stones 108 

CII.'VPTKR   \T 

Ri(;irr  iivi-ociiondriac  I'AIX 

Cask  N'o, 

o'l.    Peril  ardial    LlTusion :o^ 

07.    Renal   Stone .'oS 


;  TABLE   OF   CONTENTS 

Case  No.  Page 

98.  Catarrhal  Jaundice 210 

QQ.  Hepatic  Cancer 211 

100.  Alcoholic  Gastritis 214 

loi.  Fibrous  Endocarditis  of  the  Mitral  and  Aortic  Valves,  with  InsuflQciency 

of  Both 215 

102.  Phthisis 217 

103.  Acute  Cholecystitis 219 

104.  Hepatic  Syphilis 220 

105.  Hiingebauch 222 

106.  Stone  in  Ductus  Choledochus 224 

107.  Debility;  Floating  Kidney 225 

108.  Debility 227 

109.  Subdiaphragmatic  Abscess 229 

no.  Pancreatic  Cancer 230 

111.  Pericecal  Tuberculosis 233 

112.  Duodenal  Ulcer  (Local  Peritonitis) 234 

113.  Hysteria  Minor 236 

114.  Cholecj^stitis  Complicating  Typhoid  Fever 238 


CHAPTER  VII 

PAIN  IN  THE  LEFT  HYPOCHONDRIUM 

Case  Xo. 

115.  Pyonephrosis  with  Stone 242 

116.  Functional  Angina  Pectoris 243 

117.  Congenital  Cystic  Kidneys 246 

118.  Myeloid  Leukemia 247 

1 19.  Renal  Infection 250 

1 20.  Hyperchlorhydria 251 

121.  Renal  Stone 253 

122.  Hypernephroma 255 

123.  Tuberculous  Enteritis 256 


CHAPTER   VIII 

RIGHT   ILIAC   PAIN 

Case  Xo. 

1 24.  Pericecal  Tuberculosis 258 

125.  Pericecal  Tuberculosis 261 

126.  Tuberculosis  of  the  Cecal  Region 261 

127.  Normal  Pregnancy 262 

128.  Ow'irian  Cyst  with  Twisted  Pedicle 263 

1 20.  Tabes  ]Mesenterica 204 

130.  Ovarian  Cyst  with  Twisted  Pedicle 265 

131.  Ruptured  Ovarian  ("\st 2()6 

132.  Oxarian  ("}-st 267 

133.  Stone  in  the  Right  Ureter 268 

134.  Tuberculosis  of  Right  Tuljc 268 

135.  -Mucous  Colitis 260 

136.  Ajipendicuiar  Colic  (Chronic  Appendicitis) 270 

137.  Stone  in   Both   Kidnc_\-s 272 


TABLE   OF   CONTENTS  9 

CHAPTER  IX 

LEFT  ILIAC   PAIN 

Case  No.  Page 

138.  Perforated  Gastric  Ulcer 277 

139.  Bladder  Cancer 278 

140.  Constipation 280 

141.  Syphilitic  Adenitis 281 

142.  Multilocular  Ovarian  Cyst  (Twisted  Pedicle) 282 

142a.  Diverticulitis 284 

General  Consideration  of  the  Diagnosis  of  Abdominal  Pain 286 


CHAPTER  X 

AXILLARY   PAIN 

Case  No. 

143.  Pneumonia 288 

144.  Broken  Rib 292 

145.  Unknown  Infection 293 

146.  Angina  Pectoris 295 

147.  Syphilitic  Heart  and  Aorta 296 

148.  Pneumothorax  (Pulmonary  Tuberculosis) 298 

149.  Pleural  Effusion 300 

150.  .Vrtificial  Menopause 302 

151.  Typhoid  Fever 303 

152.  Weak  Heart;  .\cute  Pulmonary  Edema 305 

153.  Gall-stones 307 

1 54.  Sepsis  with  Thrombi 308 

155.  Pus  Kidney  (Tuberculosis  ?) 310 

156.  Neurosis 312 

157.  Pericarditis 313 

1 5S.  Thoracic  .\neurysm 315 

159.  Old  Pleurisy 317 

160.  Intercostal  Neuralgia 319 

161.  Costal  Tuberculosis 320 

162.  Starvation 1,20 


CHAPTER   XI 

PAIN   IN   THK    ARMS 


Case  .No, 


163.  Traumatit'  Neurosis 

164.  Aneurysm   (Called   Rheumatism)     . 
i()v  Mcdiastiiiai   .Xcoplasm   (Metastatic). 

i()().  Neuralgia 

i(>7.  Infci  lious  Cellulitis  with   .Arthritis 

lOS.  Tuberculosis  of   the   Humerus 

itH).  Sci)tic  Osteomyelitis 

I  70.  Cellulitis 

171.  Cer\i(  al    Rib 

17 J.  Sarcoma  Hunuri 

1  73.  Sarcoma  Humeri 


^4 


10  TABLE    OF    CONTENTS 

Case  No.  Page 

1 74.  Septic  Osteomyelitis 340 

1 75.  Thoracic  Aneurysm 341 

176.  Angina  Pectoris  (Syphilitic  Aortitis  ?) 343 

177.  Metastatic  Hypernephroma 344 

1 78.  Malignant  Lymphoma 346 


CHAPTER  XII 

PAIN  IN  THE  LEGS  AND   FEET 
Case  No. 

179.  Gonorrheal  Arthritis 350 

180.  Arteriosclerosis;  Chronic  Nephritis;  Pleural  Effusion;  Terminal  Infection.  .  353 

181.  Psoas  Spasm  Due  to  Nephrolithiasis 355 

182.  Psoas  Tear 357 

183.  Pott's  Disease  with  Psoas  Abscess;  General  Tuberculosis 358 

184.  Sciatica 359 

185.  Neuritis  with  Herpes  Zoster 360 

186.  General  Pyogenic  Infection 363 

187.  Gout 365 

188.  Fractured  Pelvis  and  Sepsis 366 

189.  Acute  Infection  of  the  Hip 368 

190.  Tabes  Mesenterica;  General  Tuberculosis 369 

191.  Flat-foot;  Psychoneurosis 371 

192.  Acute  Foot-strain 372 

193.  Alcoholic  Neuritis 373 

194.  Pneumococcus  Arthritis,  Endocarditis  (?),  and  Pneumonia 375 

195.  Gout 376 

196.  Pelvic  Neoplasm 380 

197.  Carcinoma  Uteri '.  .  381 

198.  Sarcoma  of  the  Femur 383 

199.  Septic  Knee 385 

200.  Hysteria 385 

201.  Syphilis 386 

202.  Gout  and  Gonorrhea 387 

203.  Syphilis i&Q 

204.  Cerebrospinal  Syphilis  (Vascular  Crisis  ?) 301 

205.  Gonorrheal  .\rthritis 3Q- 

206.  Sepsis 304 

207.  Flat-foot 305 

208.  Sacro-iiiac  Strain 305 

209.  Sy[)hililic  Periostitis 397 

210.  Syphilitic  Periostitis 308 

211.  Pneumonia 3Q0 

212.  Ischiorectal  Abscess 400 


CHAPTER   XIII 
FEVERS 

SilORT    FkVF.KS 405 

XUN-INFECTIOI  S    Fk\ERS 405 


TABLE    OF   CONTENTS  H 

Case  Xo.  Page 

213.  Renal  Infection  (Bacillus  Coli) 406 

214.  Syphilis 407 

215.  Pulmonary  Tuberculosis '  .  .  .  409 

216.  Septic  Thrombosis  of  the  Lateral  Sinus  and  Jugular  Vein 410 

217.  Perirectal  Abscess;  Perinephric  Abscess 41 1 

218.  Syphilis 413 

219.  Interlobar  Postpneumonic  Empyema 415 

220.  Poliomyelitis;  Renal  Infection 416 

221.  Typhoid  Fever  with  Relapse 418 

222.  Typhoid  Fever  (Brief) 420 

223.  Typhoid  Fever  (Afebrile  when  First  Seen) 422 

224.  Typhoid  Fever;  Impaction;  Dysuria 423 

225.  Pleurisy  (Tuberculous)  424 

226.  Pericecal  Tuberculosis 426 

227.  Phthisis 428 

228.  Malignant  Endocarditis 430 

229.  \'ascular  Crisis 432 

230.  Pneumonia  and  General  Pneumococcus  Infection 435 

23 1 .  Sepsis 437 

232.  Pleural  Effusion 439 

233.  Epidemic  Meningitis 441 

234.  Unknown  Infection 443 

2^^^.  Pneumonia 444 

236.  Pneumococcus  Infection 446 

237.  Urticarial  Fever 447 

238.  Pharyngeal   (and  Transi)haryngeal)   Infection 449 

239.  Streptococcus  Sejjsis 449 

240.  Otit  is  Media 451 

241.  Glandular  Fever 452 

242.  Catarrhal  Jaundice 454 

243.  Miliar}'  Tuberculosis 454 

244.  Esti\o-autumnal  Alalaria 456 


CHAPTER   XIV 

CHILLS 
Cask  No. 

245.  Hepatic  and  Pulmonar}'  Abscess 4()2 

246.  Hysteria   ( with   Arteriosclerosis  ?) 404 

247.  Intluenza 405 

248.  Chronic  ( iloniiTuldiicpliritis 407 

240.  Otitis   Media 4()9 

250.    i'lilliisis 470 

2,1.    I'htliisis 471 

252.  Double    Pleurisy    (Septic  ?) 473 

253.  Pneumonia 475 

254.  \'is(erai   Syphilis 477 

255.  T>'plioi(l    I''e\-er 478 

25(1.    Ischiorectal   .Xhscess 4S1 

237.   Gall-stones 4S3 

258.   Deep  .Vxillary  Absc  ess 4^'4 


12  TABLE   OF   CONTENTS 

CHAPTER   XV 

t 

COMA 

Page 

Examination  of  Comatose  or  Convulsive  Patients 486 

Certain  Hoary  Errors  to  be  Avoided 486 

Causes  of  Coma  and  Convulsions 486 

Valuable  Clues 490 

Case  No. 

259.  Stokes-Adams'  Disease 492 

260.  Mitral  Disease  (and  Hysteria  ?) 493 

261.  Chronic  Valvular  Disease;  Sudden  Heart  Failure  from  Unknown  Cause.  .  495 

262.  Cerebral  Tumor  (?) 496 

CHAPTER  XVI 

CONVULSIONS 

Case  No. 

263.  Alcoholism 501 

264.  Hysteria 502 

265.  Hysteria 503 

266.  Epidemic  Meningitis 508 

267.  Chronic  Interstitial  Nephritis;  Vascular  Crisis 511 

268.  Chronic  Interstitial  Nephritis;  Uremia 513 

269.  Otitis  Media 514 

270.  General  Paralysis 516 

271.  Stokes- Adams'  Disease 518 

272.  Stokes-Adams'  Disease 520 

273.  Tonsillitis  and  Congenital  Heart   Disease 522 

274.  Cerebral  Tumor 523 

275.  Dementia  Paralytica 525 

276.  Lead-i)oisoning 527 

277.  Syphilis 529 

CHAPTER   XVII 

WEAKNESS 

Case  No. 

278.  Addison's  Disease 535 

279.  AkohoHsm 53^ 

280.  Secondary  Anemia;  Piles 539 

281.  Pernicious  .\nemia 54° 

282.  .Apprehension 54- 

2S3.   Chlorosis 544 

284.  Empyema  (Tuberculous  ?) 545 

285.  Empyema 547 

286.  Gastric  Cancer 548 

287.  Cancer  of  the  Liver 550 

288.  Diabetes  Mellitus 551 

289.  Diabetes  Mellitus 553 

290.  Lead-]:)oisoning 554 

29T.  Myeloid  Leukemia 555 


TABLE   OF   CONTENTS  1 3 

Case  No.  Page 

292.  Alcoholic  Neuritis 557 

293.  Chronic  Plastic  Pleurisy 559 

294.  Convalescence  from  Pneumonia 560 

295.  Psychoneurosis 562 

296.  Pus-tube 563 

297.  Staphylococcus  Sejisis 565 

298.  Phthisis 567 

299.  Vertebral  Tuberculosis 568 

300.  Pernicious  Anemia 570 

301.  Graves'  Disease 572 

302.  Myxedema 573 


CHAPTER   XVIII 

COUGH 

Varieties  of  Couch 576 

Case  No. 

303.  Pulmonary  .Vbscess 579 

304.  Aneurysm 582 

305.  Bronchitis  and  .\])[)endicilis 584 

306.  Bronchitis  and  Asthma 585 

307.  Streptococcus  Bronchopneumonia 587 

308.  Bronchiectasis 588 

30().  lironchitis;  Bronchopneumonia;  Bronchiectasis;  Emphysema 590 

310.  Pneumonia 591 

311.  Pneumonic  Phthisis 503 

312.  Traumatic  Pneumonia 5()() 

313.  Phthisis 590 

314.  Miliary  Tuberculosis  and  Diabetes Ooo 

315.  Syphilitic  Disease  of  the  Lung bo2 

316.  Tuberculosis  of  the  Lungs,   Chronic  Interstitial   Nephritis,   Hypertrojjhy 

and    Dilatation   of   the    Heart.   Tubercular  Ulcers   of   the    Intestine. 

Hypernephroma O04 

317.  Internal  Urticaria ()05 


CHAPTER   XIX 

VOAHTINC; 

Imi'ortant  Factors  in  the  I'rodittion  ok  X'omiting 611 

Cask   No. 

3 1 8.  .Mcoholism 

310.   .Xppendicitis 

3  JO.   (iaslric   Camer 

3.!i.   Gastric   Cancer 

322.   Cancer  of   the   Sigmoid 

,1,2,!,.   Ciilorosis    .         

324.   Const i])al ion    (Neurosis  ?) 

32  V    Constipation    (  Neurosis  ?) 

32().    Calarriial   Jaundice 

327.    Lxhaustion 


:4 


14  TABLE   OF    CONTENTS 

Case  No.  Page 

328.  Tabes  with  Gastric  Crisis 630 

329.  Traumatic  Neurosis 631 

330.  Gastric  Neurosis 633 

331.  Neurosis;  Gastroptosis 635 

332.  Gastric  Ulcer;  Pyloric  Stenosis 637 

333.  Tertian  Malaria 639 

334.  Malaria  (Tertian) 642 

335.  Tuberculous  Meningitis 643 

336.  Incomplete  Miscarriage 645 

337.  Chronic    Interstitial    Nephritis,   Enteritis    and    Gastritis    with    Chronic 

Colitis  and  Terminal  Streptococcus  Septicemia 646 

338.  Nervous  Exhaustion 649 

339.  Phthisis 650 

340.  Pneumonia 652 

341.  Vomiting  of  Pregnancy;  Pleural  Effusion 654 

342.  Mitral  Stenosis 656 

343.  Cancer  of  the  Ascending  Colon 657 

344.  Hysteria;  Alcoholism;  Drug  Habits 659 

345.  Chronic  Intestinal  Obstruction,  Probably  Due  to  Malignant  Disease 661 

346.  Neurosis;  Morphin 662 

CHAPTER   XX 

HEMATURIA 

Causes  and  Types  of  Hematuria 667 

Case  No. 

347.  Tuberculosis  of  the  Kidney  and  Bladder 669 

348.  Tuberculosis  of  the  Bladder;  Renal  Tuberculosis  (?) 670 

349.  Renal  Neoplasm 671 

350.  Chronic  Nephritis 673 

351.  Cancer  of  the  Bladder 674 

352.  Cystitis  of  Unknown  Origin 675 

353.  Papillary  Cystadenoma  of  the  Kidney 677 

354.  Hematuria,  Cause  Unknown 678 

355.  Renal  Irritation  from  Oxaluria 680 

356.  Hypernephroma 681 

357.  Gastric  Ulcer;  Hematuria,  Cause  Unknown 682 

358.  C3-stitis;    Enuresis 683 

CHAPTER   XXI 

DYSPNEA 

Causes  of  Dyspnea 689 

The  Effect  of  Position  and  of  the  Time  of  Day 690 

Cheyne-Stokes'    Breathing 690 

Case  No. 

359.  Hysteria;    Polypnea 6qo 

360.  Aortic  Stenosis  and  Regurgitation 694 

361.  Infectious    Endocarditis,    Myocarditis,    and    Pericarditis;    Mitral    Stenosis 

and  Regurgitation 695 

362.  Hyperplastic  Endometritis;  Debility 698 


TABLE   OF   CONTENTS  1 5 

Case  No.  Page 

363.  Bronchitis  and  Emphysema;  Epilepsy 700 

364.  Tuberculous  Empyema  and  (Presumably)  Phthisis 701 

365.  Acute  Cardiac  Dilatation,  Cause  Unknown 704 

366.  Acute  Laryngitis 706 

367.  Croup 708 

368.  Chronic  Glomerulonephritis 709 

369.  Myocardial  Insufficiency 710 

370.  Mitral  Stenosis  and  Regurgitation 711 

CHAPTER   XXII 

JAUNDICE 

Types  and  Causes  of  Jaundice 715 

Associated  Symptoms 716 

Intensity  of  Jaundice 719 

Case  No. 

371.  Catarrhal  Jaundice 719 

372.  Catarrhal  Jaundice 721 

373.  Tertian  Malaria 722 

374.  Gall-stones 723 

375.  Gall-stones 724 

376.  Pancreatic  Cancer 726 

377.  Acute  Yellow  Atrophy  of  the  Liver 727 

CHAPTER  XXIII 

NERVOUSNESS 
Case  No. 

378.  Diabetes  Mellitus 731 

379.  Phthisis 733 

380.  Suppurative  Nephritis 735 

381.  Endothelioma  of  the  Pleura;  Acute  Serofibrinous  Pericarditis  and  General 

Arteriosclerosis 738 

382.  Pernicious  .\nemia 739 

383.  Chronic  Interstitial  Nephritis 741 


Appendices 743 

Index 747 


DIFFERENTIAL  DIAGNOSIS 


INTRODUCTION 

I.  THE  PRESENTING  SYMPTOM 

Cases  of  disease  present,  as  we  say,  certain  leading  symptoms. 
They  thrust  forward,  like  a  soldier  who  presents  arms,  a  complaint  such 
as  pain,  cough,  or  "nervousness,"  so  that  it  occupies  the  foreground 
of  the  clinical  picture.  Such  a  ^^ presenting  symptom,''^  comparable  to 
the  "presenting  part^'  in  obstetrics,  may  turn  out  to  be  of  minor  im- 
portance when  we  have  studied  the  whole  case.  But  at  the  outset  it 
has  the  power  to  lead  us  toward  right  or  wrong  conclusions  in  diagnosis, 
prognosis,  and  treatment,  according  as  we  ha^•e  or  have  not  learned 
the  art  of  following  it  up. 

This  book  is  an  attempt  to  study  medicine  from  the  point  of  view 
of  the  presenting  symptom.  I  hope  to  show  how  the  complaints  of  the 
patient — fragmentary  expressions  of  the  underlying  disease — should  be 
used  as  leads,  and  how  their  lead  can  be  followed  to  the  actual  seat  of 
the  disease. 

The  plan  thus  outlined  has  three  parts: 

(a)  To  present  a  list  of  the  common  causes  of  the  symptoms 
most  often  complained  of  by  patients,  e.  g.,  the  causes  of  pain 
in  the  back,  of  vomiting,  or  of  hematuria. 

(b)  To  classify  these  causes  in  the  order  of  their  frequency, 
so  far  as  this  is  possible. 

(c)  To  illustrate  them  by  case-histories  in  which  the  present- 
ing symptom  is  followed  home  until  a  diagnostic  ]:)roblem 
and  its  solution  are  ])resentcd. 

2.  THE  GROUPING   OF  REASONABLE  POSSIBILITIES 

Diagnoses  are  missed — (a)  Usually  because  physical  signs  are  not 
recognized;  {b)  occasionally  because  we  do  not  think  correctly. 

This  book  will  not  help  any  one  to  recognize  the  signs  of  disease, 
but  it  ought  to  aid  physicians  to  solve  those  clinical  puzzles  wherein 
the  diagnosis  is  missed  because  the  ])atient's  disease  is  not  among  tlic^sc 

2  17 


l8  DIFFERENTIAL   DIAGNOSIS 

considered  and  looked  for.  In  other  words,  correct  diagnosis  depends 
upon  what  enters  the  doctor's  head  as  possible,  and  on  what  his  head 
does  to  sift  the  possibilities  after  they  have  entered  it,  as  well  as  on  the 
direct  recognition  of  signs  by  physical  examination. 

To  throw  open  the  mind's  door  and  allow  all  disease  to  enter  into 
consideration  each  time  that  we  are  called  to  a  bedside  is  foolish  in  the 
attempt,  and  impossible  in  the  performance.  Each  case  should  lead 
us  to  arrange  before  the  mind's  eye  a  selected  group  of  reasonably  prob- 
able causes  for  the  symptoms  complained  of  and  for  the  signs  discovered. 
What  we  select  should  depend  upon  the  clues  furnished  us  by  the 
patient  himself,  or  by  the  results  of  our  own  examination. 

When,  for  example,  a  patient  pronounces  the  word  ^'  headache,^'  a 
group  of  causes  should  shoot  into  the  field  of  attention  like  the  figures  on 
a  cash  register.  Blue  lips  and  finger-nails  call  up  quite  another  group 
of  ideas.  Each  clue  or  combination  of  clues  should  come  to  possess 
its  own  set  of  radiations  or  "leadings,"  determined  partly  by  what  we 
know  of  anatomy  and  physiology,  partly  by  the  hard  knocks  of  clinical 
experience. 

3.  ADVANTAGES  OF  THE  PLAN  HERE  ADOPTED 

This  way  of  working  into  a  knowledge  of  medicine  has  the  advantage 
of  following  the  course  of  procedure  by  which  we  often  question  and 
examine  patients  in  the  office  or  in  the  clinic.  We  begin  with  the  chief 
complaint  and  work  inward  and  backward  to  the  causes,  the  organic 
lesions,  the  evolution,  probable  outcome,  and  rational  treatment  of  the 
case.  Cases  do  not  often  come  to  us  systematically  arranged  like  the 
account  of  typhoid  in  a  text-book  of  practice  of  medicine.  They  are 
generally  presented  to  us  from  an  angle,  and  with  one  symptom,  often  a 
misleading  one,  in  the  foreground.  From  this  point  of  view  we  must 
reason  and  inquire  our  way  back  into  the  deeper  processes  and  more 
obscure  causes  which  guide  our  therapeutic  endeavors. 

\\'hy  do  so  many  practitioners  treat  symptoms  only?  Why  are  their 
diagnoses  and  the  resulting  treatment  so  full  of  vagueness,  groping, 
hedging,  and  "shot-gun"  prescriptions? 

Because  they  do  not  know  how  to  get  beyond  symptoms.  They 
ha\"e  not  been  Uiught  from  the  point  of  \iew  of  practice — /.  f.,  of  the 
presenting  symptom.  What  are  the  possible  causes  and  linkages  of 
any  symptom?  Which  of  them  are  most  probable?  Bv  what  methods 
of  questioning  or  of  examination  can  the  actual  cause  be  found?  This 
book  aims  to  put  into  the  physician's  hand  the  means  of  answering  these 
questions. 


INTRODUCTION  1 9 

I  quite  realize  that  the  art  of  forming  reasonable  hypotheses  about  a 
case  of  disease  and  then  of  testing  these  hypotheses  by  such  experiments 
as  shall  establish  the  correct  and  nullify  the  incorrect,  is  useless  unless 
the  methods  of  physical  and  chemical  diagnosis  have  been  mastered  and 
unless  the  natural  history  of  all  common  diseases  has  been  learned  by 
observation  and  reading.  But  experience  shows  that  a  man  may  pos- 
sess a  considerable  acquaintance  with  physical  diagnosis  and  with  the 
course  of  disease,  and  yet  be  quite  helpless  in  the  presence  of  a  suffering 
person,  simply  because  he  cannot  apply  his  knowledge  to  this  case. 
He  can  observe,  he  can  remember,  but  he  cannot  constructively  think 
and  experiment.  Every  item  of  physical  or  chemical  examination  is  an 
experiment  made  to  test  the  soundness  of  an  idea  about  the  case  in  hand. 
Skill  in  thinking  and  in  putting  our  thoughts  to  such  a  test  of  experiment 
are  not  learned  either  by  drill  in  physical  diagnosis  or  by  reading  upon 
the  history  of  disease. 

To  give  such  practice  in  thinking  and  working  one's  way  into  the 
mastery  of  a  case  of  disease,  through  the  intelligent  verification  of  our 
thoughts  by  physical  examination,  is  my  object  in  the  following  chap- 
ters. They  follow  the  method  of  case-teaching  which  I  have  used  for 
eight  years  at  the  Harvard  Medical  School,  applying  there  a  method  long 
employed  at  the  Harvard  Law  School,  and  first  described  by  Dr.  W. 
B.  Cannon. 

4.  LIMITS 

To  keep  the  book  within  reasonable  limits  I  have  selected  12  symp- 
tomfe  (see  Table  of  Contents)  which  are  most  often  complained  of  by 
patients.  I  am  well  aware  that  others,  such  as  diarrhea,  constipation, 
loss  of  weight,  paralysis,  pallor,  edema,  purpura,  or  palpable  tumors, 
might  well  ha^•e  been  discussed  did  space  permit. 

5.   VULNERABILITY   OF   ALL  DIFFERENTIAL  DIAGNOSIS 

The  discussions  which  here  follow  each  ])rintcd  case  arc  concerned 
with  differential  diagnosis,  a  very  dangerous  topic — dangerous  to  the 
reputation  of  physicians  for  wisdom.  It  is.  I  suppose,  owing  to  this 
danger  that  so  little  has  been  written  on  differential  diagnosis  and  so 
nuich  on  diagnosis  (non-differential).  To  state  the  symptoms  of  ty])hoid 
perforation  is  not  dilTicult.  To  gi^•e  a  set  of  rules  whcre1)y  the  condi- 
tions which  simulate  ty])hoid  perforation  may  l)e  excluded  is  exceedingly 
difficult.  Pliysicians  are  very  naturally  reticent  on  such  matters,  slow 
to  commit  their  thoughts  to  |)a])er,  and  ^■ery  susjMcious  of  any  attempt 
to  tabulate  their  methods  of  rcasonini.'. 


20  DIFFERENTIAL  DIAGNOSIS 

Yet  all  diagnosis  must  become  differential  before  it  can  be  of  any  use. 
All  recognition  of  a  lesion  or  a  disease  involves  distinguishing  possible 
sources  of  error  and  excluding  them  by  a  reasoning  process — more  or 
less  definite  and  conscious.  To  be  of  any  value,  then,  diagnosis  must 
descend  into  the  arena  where  it  is  questioned  and  assailed,  where  all 
sorts  of  errors  and  uncertainties  arise  to  unsettle  our  wisdom.  Those 
differential  tables  which  we  all  distrust  so  much  are  really  no  more 
untrustworthy  than  the  diagnoses  we  make  in  practice — for  every  diag- 
nosis expresses  the  results  obtained  by  using  such  a  table  more  or  less 
unconsciously,  as  we  exclude  possible  errors  and  alternative  diagnoses. 

I  am  very  well  aware,  therefore,  that  the  differential  diagnostic  state- 
ments which  fill  this  book  are  one  and  all  subject  to  such  limiting  phrases 
as  "in  most  cases,"  "as  a  rule,"  etc.  This  must  always  be  so  as  long  as 
the  list  of  possible  causes  or  diagnoses  which  we  call  to  mind  when  we 
attack  any  diagnostic  problem  is  an  incomplete  list  (or  possibly  an  over- 
inclusive  one) .  To  decide  which  of  the  known  causes  of  jaundice  is  the 
cause  of  the  yellowness  of  Miss  Smith  we  investigate,  by  the  experiments 
known  as  "history,"  "physical  examination,"  and  "therapeutic  test," 
a  list  of  these  known  causes.  But  some  day  we  may  meet  a  case  in  which 
none  of  these  well-known  causes  is  present.  Some  new  cause,  so  far 
unlisted,  may,  in  fact,  be  at  work.  There  are  probably  as  many  fish  in 
the  sea  as  ever  came  out  of  it;  the  unrecognized  infections,  poisons, 
and  maladjustments  are  probably  as  many  as  those  already  described  in 
text-books. 

All  this  unconquered  territory  lies  about  us,  full  of  hidden  dangers  to 
our  differential  diagnosis — i.  e.,  to  all  practical  diagnosis. 

One  other  limitation  must  be  mentioned.  Whenever  one  says: 
"The  symptoms  produced  by  typhoid  (or  by  peritonitis  or  by  renal 
stone)  are  such  and  such,"  one  should  tacitly  add — "provided  that  it 
produces  any  characteristic  symptoms  at  all."  It  is  certain  that  the 
three  diseases  just  mentioned  may  exist  without  producing  any  symp- 
toms of  which  the  jjatient  is  aware.  It  is  probable  that  this  is  true  of 
all  other  diseases.  But  as  we  can  have  no  direct  dealing  with  these 
silent  types  of  disease,  we  can  give  them  place  in  the  theater  of  our 
reasonings  only  in  that  outer  circle  reserved  for  "possible  sources  of 
error,"  a  great  and  distinguished  company  whose  presence  serves  to  keep 
us  within  the  bounds  of  humility  and  of  scientific  caution. 

Meantime  we  must  go  on  with  our  work  of  finding  the  most  prob- 
able among  the  known  causes  and  discoverable  types  of  disease. 


INTRODUCTION  21 

6.  OMISSIONS 

Some  diseases  are  omitted  by  choice,  others  by  necessity.  The  385 
cases  which  I  have  selected  for  study  were  all  seen  in  private  or  hospital 
practice.  To  prevent  the  possibility  of  their  recognition  by  the  individ- 
uals concerned  I  have  changed  or  omitted  certain  personal  details. 
In  essentials  the  cases  are  reproduced  as  they  were  observed. 

I  have  chosen  no  cases  in  which  diagnosis  was  obvious  and  none  in 
which  it  was  impossible  or  dependent  chiefly  on  good  luck.  To  avoid 
the  obvious,  I  have  omitted  discussion  of  such  clinical  pictures  as  the 
following: 

Patient  of  twenty-five,  who  has  had  two  attacks  of  rheumatic  fever,  complains  of 
dyspnea,  dropsy,  and  cough.  Examination  shows  a  rapid,  irregular,  transversely  enlarged 
heart,  with  a  presystolic  murmur  and  thrill  at  the  apex  and  an  accentuated  pulmonic 
second  sound.  There  is  evidence  of  passive  congestion  of  the  lungs,  liver,  legs,  and  gas- 
Iro-intestinal  tract,  with  dropsy  of  the  serous  cavities. 

There  may  be  many  difficulties  in  physical  examination  here,  but 
none  in  the  reasoning  processes  which  lead  us  to  the  examination  and 
thence  to  our  conclusions.  Obvious  maladies,  such  as  pharyngitis, 
perii)heral  gangrene,  or  talij^es,  have  been  omitted  for  the  same  reason; 
likewise  all  those  in  which  diagnosis  is  made  only  by  incision;  e.  g.,  acute 
pancreatitis,  certain  breast  tumors. 

While  selecting  cases  in  which  diagnosis  was  difficult,  but  not  impos- 
sible, I  have  tried  to  choose  those  in  which  in  the  end  we  could  attain  a 
reasonable  certainty.  Absolute  certainty  is  attainal^le  only  as  the  result 
of  of)eration  or  autopsy,  and  not  always  then.  Hence  it  is  possible  that 
certain  of  my  readers  may  disagree  with  the  diagnosis  Imally  reached  in 
some  cases.  This  is  inevitable  in  a  book  of  this  kind,  as  it  is  in  actual 
practice.  Book  and  practice  aHke  can  only  reflect  the  existing  state  of 
medical  knowledge,  medical  uncertainty,  and  ignorance.  But  1  sin- 
cerelv  hope  that  my  errors  may  be  pointed  out  by  correspondents. 

After  restricting  the  field  in  the  way  just  mentioned,  I  have  tried 
to  exemplify  in  each  cha|)ter  all  the  diseases  which  often  lead  a  ])atic'nt 
to  consult  his  pln-sician,  comj)laining  of  the  symptom  which  forms  tlie 
sul)ject  of  that  cha])ter.  Xow  and  then,  however,  I  have  altogether 
omitted  some  imitortant  disease  because  T  could  not  find  an}-  suit;il)le 
example  of  it  within  my  own  cases  or  among  those  wliicli  I  had  myself 
stucHed. 

In  a  few  cases  certain  items  lia\"e  l)een  omilted  here  because  they 
\\ere  hkewise  omitted  in  the  \ersion  of  the  case  gi\en  me  Ity  tlie  atten(hng 
[)liysieian.     ]M\-   task   was  lo  iiolicc  their  ioiispi(  nous  or   inronspicunus 


22  DIFFERENTIAL  DIAGNOSIS 

absence,  and  to  act  accordingly.     It  seems  justifiable,  therefore,  to  impose 
a  similar  task  upon  my  readers. 

7.  EXPLANATION  OF  DIAGRAMS  AND  CHARTS 

The  book  contains  figures,  tables,  diagrams,  and  charts.  The  two 
last  need  some  explanation. 

The  diagrams,  which  are  introduced  in  each  chapter  just  before  the 
illustrative  cases,  represent  an  attempt  (the  first  that  I  know  of)  to  esti- 
mate the  relative  frequency  of  the  commoner  causes  for  each  symptom 
discussed.  This  estimate,  which  can  be  but  approximate,  rests  upon  the 
following  data: 

(a)  An  enumeration  of  the  total  number  of  cases  of  every  disease 
treated  at  the  Massachusetts  General  Hospital  during  the  last  six  years. 
About  180,000  cases  are  thus  classified  according  to  diagnosis,  and  the 
relative  frequency  of  eacli  disease  in  this  material  is  thus  roughly  com- 
puted. But  these  figures  do  not  give  us  the  relative  frequency  of  any  of 
the  symptoms  (such  as  jaundice  or  headache)  studied  in  this  book. 
Many  cases  of  gall-stones  are  not  jaundiced;  hence  we  cannot  directly 
compare  the  number  of  gall-stone  cases  with  the  number  of  cirrhoses 
(for  example),  but  must  estimate  the  percentage  of  jaundiced  cirrhoses 
and  jaundiced  gall-stone  disease  in  each  group.  This  is  done  by  con- 
sulting— 

{b)  Statistical  articles  from  the  literature  in  which  the  percentage 
occurrence  of  each  symptom  in  a  large  series  of  cases  is  worked  out. 
Such  statistical  articles,  however,  are  not  common.  In  Rollcston's 
magnificent  monograph  on  the  liver  almost  every  statement  has  a 
statistical  basis,  and  the  wearisome  recurrence  of  phrases  like  "as  a 
rule,"  "not  infrequently,"  "sometimes,"  etc.,  is  replaced  by  concrete 
quantitative  estimates.  But  there  are  not  many  such  books.  Hence 
I  have  been  forced  in  some  instances  to  compute  the  percentage  occur- 
rence of  a  symptom  by — 

(c)  The  study  of  the  symptom  and  of  the  frequency  of  its  occur- 
rence in  250  cases  of  the  disease  in  question;  these  cases  were  taken 
from  the  more  recent  records  of  the  ^Massachusetts  General  Hos])ital. 

By  the  methods  described  under  (a),  {b),  and  (c)  the  length  of  every 
line  in  every  diagram  has  l)ecn  calculated.  I  am  well  aware  that  tliere  are 
numerous  sources  of  error  in  these  calculations.  The  diagnoses  in  the 
^Massachusetts  General  Hospital  records  ma}'  be  faulty  in  some  instances, 
though  the  large  number  of  cases  used  tends  to  minimize  such  errors. 
The  statistical  articles  referred  to  under  {b)  may  be  incorrect,  and  do  not 
often  include  a  very  large  bulk  of  cases.     Finally,  the  number  of  cases 


INTRODUCTION 


23 


referred  to  in  the  calculations  under  (c)  is  smaller  than  I  should  wish. 
More  important  than  any  of  these  errors  are  the  absolute  omissions  which 
are  sure  to  be  discovered  among  my  tables  of  causes.  I  hope  for  much 
aid  from  my  critics  in  supplying  such  missing  links.  Indeed,  I  am  con- 
fident that  some  one  will  be  so  indignant  at  my  mistakes  that  he  will  at 
once  begin  to  write  a  better  book  on  similar  lines — a  result  which  I  most 
earnestly  desire. 

The  sources  of  my  information  regarding  the  figures  used  in  the  dia- 
grams are  given  in  Appendix  A,  p.  743. 

The  list  of  causes  represented  in  these  gridiron-shaped  diagrams  is 
not  wholly  the  same  as  that  exemplified  in  the  illustrative  cases.  Only 
the  commonest,  clearest,  and  most  important  causes  are  drawn  in  upon 
the  "gridirons."  Still  a  third  group  of  causes,  which  do  not  lend  them- 
selves either  to  diagrammatic  or  to  detailed  illustrative  treatment,  are 
mentioned  briefly  in  the  introductory  section  of  each  chaj^ter.  Hence 
the  complete  list  of  causes  discussed  is  to  be  found — (a)  In  part  in  the 
gridirons;  (b)  in  part  in  tlie  illustrative  cases;  (c)  in  part  in  the  intro- 
ductory section  of  each  chapter. 

The  Charts. — Beside  the  three  lines,  which  represent  in  the  ordinary 
way  the  course  of  temperature,  pulse,  and  respiration,  there  is  a  fourth 
line  interwoven  with  the  respiratory  curve,  and  distinguished  by  the 
presence  of  cross  stria;,  like  the  railroads  on  a  map.  This  line  stands  for 
the  twenty-four-hour  amount  of  urine  measured  in  ounces. 

In  the  charts  the  line  of  this  type     'f  1  '  '  n.irtd.  miMnimrnmnniin 

indicates  the  amount  of  urine  in  ounces,  while  the  line  cut  by  sUirs,  as 
follows,  * * *  represents  the  blood-pressure. 


CHAPTER  I 

PAIN 
GENERAL  CONSIDERATIONS 


Before  we  begin  to  study  the  cause  or  the  cure  of  any  pain,  we  need 
to  convince  ourselves  that  it  really  exists.  Not  only  in  the  cases  of 
deliberate  deception  or  malingering,  but  in  dealing  with  perfectly  honest 
people,  we  are  liable  to  error.  Many  persons,  especially  of  the  less 
educated  classes,  do  not  distinguish  between  pain  and  the  other  varieties 
of  discomfort,  such  as  itching  or  a  sense  of  pressure.  Many  patients  who 
say  at  first  that  they  have  a  headache  or  a  stomachache  may  be  brought, 
by  a  little  questioning,  to  recognize  that  they  are  referring  to  a  sense  of 
weight,  constriction,  or  vague  discomfort,  rather  than  to  pain  in  the 
narrower  sense. 

As  evidences  of  pain  we  are  accustomed  to  scrutinize: 

(a)  The  facial  expression  and  bodily  movements. 

(b)  The  account  of  some  onlooker,  such  as  a  nurse  or  relati^•e. 

(c)  The  results,  such  as  emaciation  or  muscular  weakness,  often 
produced  by  long-continued  suffering. 

(d)  The  blood-pressure. 

When  a  patient's  face  is  contorted  and  his  body  writhes,  stiffens,  or 
doubles  up,  we  can  have  no  doubt  that  he  is  suffering,  unless  we  believe 
him  an  impostor,  but  obviously  these  evidences  of  pain  may  be  easily 
simulated  or  exaggerated. 

It  is  in  such  cases  that  we  need  the  testimony  of  some  third  person 
who  can  watch  the  patient  at  a  time  when  he  supposes  himself  to  be  alone. 
Many  patients  who  do  not  intend  to  deceiA'e  us  show  far  greater  evidences 
of  suffering  when  a  doctor,  a  nurse,  or  a  friend  is  near  at  hand  than  when 
they  believe  they  are  unoljserved.  This  is  partly  due  to  the  fact  that  a 
})erfectly  genuine  though  distinctly  mild  lesion  is  very  much  more  pain- 
ful to  the  patient  when  his  self-pity  is  aroused  by  the  presence  of  a  sym- 
pathetic onlooker. 

When  a  patient  who  bears  the  ordinary  marks  of  blooming  health 
states  that  he  has  been  suffering  excruciating  pain  for  many  months, 
the  lack  of  any  of  the  ordinary  evidences  of  suffering  naturally  and 

24 


PAIN  25 

properly  make  us  take  his   statement   with  a  grain  of  salt.     Chronic 
suffering  is  pretty  sure  to  leave  its  mark  on  the  face  and  body. 

In  cases  of  suspected  malingering,  when  an  individual  states  that  a 
certain  motion  or  a  certain  pressure  upon  a  supposedly  tender  point 
causes  great  suffering,  we  may  control  his  statement  to  a  certain  extent 
by  measuring  the  peripheral  blood-pressure  at  the  time.  Severe  pain 
almost  always  causes  a  notable  rise  in  blood-pressure,  and  if  we  find  noth- 
ing of  the  kind,  we  may  rightly  conclude  that  if  pain  is  present,  it  is 
probably  not  intense. 

DEGREE  OF  PAIN 

I  have  long  been  accustomed  to  compare,  as  a  matter  of  routine  and 
in  every  case,  the  extent  and  quickness  of  the  knee-jerks  with  the  patient's 
statement  regarding  his  own  suffering.  I  ha\'e  found  that  those  who 
describe  all  their  troubles  as  "terrible,"  "awful,"  "fearful,"  and  the 
like,  are  very  apt  to  have  lively  knee-jerks,  and  that  those  who  are  more 
moderate  in  their  expressions  have  usually  less  active  reflexes.  It 
seems  quite  probable  that  there  is  a  parallelism  here  between  reflex 
sensibility  and  sensitiveness  to  pain.  Those  who  respond  to  a  given 
stimulus  by  an  exaggerated  knee-jerk  might  well  be  expected  to  res])ond 
to  a  given  cause  of  pain  by  an  exaggerated  complaint.  So  it  has  seemed 
to  me  as  a  result  of  many  observations,  and  I  have  come  to  believe  that 
people  are  more  likely  to  be  o\ersensilive  and  to  exaggerate  their  suffer- 
ings when  the  knee-jerks  are  unusually  lively. 

This  is,  of  course,  a  very  rough  and  uncertain  method  of  measuring 
pain,  and  would  ])erhaps  be  more  truly  described  as  an  attempt  to  meas- 
ure the  severity  of  the  cause  of  pain,  rather  than  of  the  pain  itself.  We 
are  greatly  in  need  of  some  more  accurate  method  of  estimating  how 
much  peo])le  suffer.  For  the  present,  we  have  to  judge  largely  by  such 
uncertain  evidences  as  were  mentioned  in  the  last  section — facial  ex])rcs- 
sion,  bodily  movement,  the  accounts  of  onlookers,  and  the  e\idences  of 
such  physical  clianges  as  ])ain  might  produce.  In  addition  to  tlicsc 
we  get  a  certain  amount  of  information  by  asking: 

"Docs  the  pain  |)revent  you  from  working?" 

"Does  it  prevent  sleep?" 

"Does  it  take  away  a])petite,  the  ca])acity  for  mo\"ement  and  en- 
joyment in  the  ordinary  functions  of  life?" 

"\\'t;  know  that  certain  races— -for  exam|)le,  the  C'liinese — are  much 
less  sensiti'.e  than  others  to  ])ain  in  that  they  exhibit  far  less  exidence  of 
"shock"  after  a  bullet  wound  or  a  (liseml)owelment.  We  can  only  u'k-s 
at  the  sensory  side  of  tliis  ])henomenon,  but  tlie  absence  of  tlie  ordinar}" 
organic  elfects  ])roduced  l)y  the  same  injury  in  a  C'auca>ian  gi\-es  us  some 


26  DIFFERENTIAL   DIAGNOSIS 

ground  for  believing  that  the  suffering  is  proportionately  small.  In  all 
probability  there  are  similar  differences  between  individuals  of  the 
same  race. 

Though  women  are  generally  believed  to  be  more  highly  organized 
and  more  sensitive  than  men,  it  is  a  well-known  fact  that  they  bear  pain, 
especially  prolonged  pain,  better  than  men.  I  have  never  heard  any 
plausible  explanation  of  this  fact. 

TYPES  OF  PAIN 

Most  of  the  adjectives  which  are  attached  to  the  complaints  of  pa- 
tients, either  by  themselves  or  in  the  text-book  description,  give  us  no  in- 
formation of  value  because  they  are  not  regularly  associated  with  any 
one  disease.  Boring  pains,  tearing  pains,  and  knife-like  pains  do  not 
characterize  any  particular  disease.  Nevertheless,  there  are  a  few  dis- 
tinctions of  importance. 

Pains  that  recur  rhythmically,  or  at  regular  intervals,  working  up 
gradually  to  a  climax  each  time,  and  then  disappearing  suddenly  or 
gradually,  are  often  associated  with  hyperperistalsis  within  some  hollow 
tube,  such  as  the  intestine,  the  ureter,  the  bile-ducts,  or  the  uterus.  To 
such  pains  the  name  of  "colic"  is  traditionally  attached,  though  it  is 
often  used  much  more  vaguely  to  denote  any  type  of  severe  and  sudden 
pain  in  the  abdomen. 

Throbbing  pains,  increased  momentarily  with  each  Ijeat  of  the  heart, 
are  characteristic  of  vascular  hyperemia,  such  as  occurs  about  the  roots 
of  an  inflamed  tooth.  In  connection  with  vasomotor  headaches  and  in 
dysmenorrhea  we  occasionally  see  the  same  phenomenon. 

Pain  luith  a  sense  of  constriction  is  of  great  diagnostic  \'alue  when  it 
occurs  in  the  precordial  region,  pointing,  as  it  does,  in  the  great  majority 
of  cases,  to  angina  pectoris  as  its  cause.  Other  diseases  producing  pain 
in  this  region  are  rarely,  if  ever,  accompanied  by  this  sense  of  constriction, 
which  the  patients  often  express  in  very  vi\-id  phrases,  e.  g.,  "as  if  I  were 
squeezed  in  a  \ise,"  or  "as  if  some  one  gripped  my  heart  in  his  hand." 

Thoracic  or  abdominal  pain  increased  or  produced  by  exertion  and 
promptly  relieved  by  rest  is  almost  always  due  to  the  cause  just  men- 
tioned— angina.  ^lany  pains  supposed  by  the  patient  to  be  due  to  in- 
digestion, to  rheumatism,  or  to  neuralgia  may  thus  be  recognized  as 
anginoid. 

Pain  that  shoots  and  darts,  es]3ecially  if  it  follows  the  course  of  some 
nerve-trunk,  usually  turns  out  to  be  neuralgic.  In  many  cases  such  a 
pain  is  associated  with  prickling,  burning,  numbness,  or  other  pares- 
thesias. 


PAIN  27 

RELATION  OF  PAIN  TO  OTHER  FACTS 

A  careful  history  of  the  bearing  of  various  factors  in  the  patient's 
habits  and  environments  upon  the  occurrence  or  the  severity  of  pain  is  of 
prime  importance  in  diagnosis.  Among  the  elements  to  be  taken  account 
of  are  the  relation  of  pain  to: 

(a)  The  time  of  day. 

(b)  The  position  of  the  body. 

(c)  The  taking  of  food. 

(d)  The  effect  of  motion  involving  the  painful  part,  or  of  jolt- 
ing of  the  entire  body. 

(e)  The  effect  of  emotional  excitement. 
(/)  The  effect  of  occupation. 

(g)  The  effect  of  season  and  the  weather. 
(h)  The  mode  of  relief — e.  g.,  by  heat,  cold,  food,  vomiting, 
medicine,  rest,  occupation. 

Neurasthenic  headaches  and  the  pains  of  chronic  joint  troubles  are 
apt  to  be  worse  in  the  morning  and  to  imj)ro\e  as  the  day  goes  on.  Any 
]jain  associated  with  fever  and  infection  is  likely  to  be  worse  in  the  even- 
ing, when  the  temperature  is  at  its  highest. 

Pains  affected  by  ])osition  are  especially  those  due  to  diseases  of  the 
joints  and  muscles,  such  as  lumbago,  sacro-iliac  strain,  all  the  types  of 
arthritis,  stiff  neck,  and  the  like.  Almost  all  varieties  of  pehic  disease 
are  worse  when  the  jtalient  is  on  her  feet,  as  the  position  is  likely  to 
in\ohe  some  pressure  or  dragging  upon  ])ainful  ])oints.  For  the  same 
reason  the  surgical  affections  of  the  kidney  and  all  diseases  which  in- 
\ol\e  splenic  enlargement  are  usually  more  painful  wlien  the  upright 
])Osition  is  assumed.  Occasionally  a  headache  is  distinctl}'  im])ro\ed  or 
aggra\ated  when  the  patient  Hes  down.  The  distress  accompanying 
uncom])ensated  cardiac  disease  is  always  aggravated  by  recumbency. 

Most  muscular  ])ains  are  aggra\ated  by  the  use  of  the  muscle;  hence 
the  ])resence  of  such  an  aggra\ation  ma}'  helj)  us  to  distinguish  muscular 
})ains  from  those  of  different  origin.  It  must  be  remembered,  liowexer, 
that  in  some  cases  the  ])ains  of  neuritis  are  increased  l)y  use  of  llie  i»art. 
even  when  no  muscular  lesion  is  disco\'erable.  The  motion  of  cougliing 
brings  great  distress  in  pleurisy,  pneumonia,  and  all  diseases  in\()l\ing 
the  intercostal  nuiscles.  Anginoid  ])ains  are  increased  not  onl}'  by 
motion,  but  by  any  other  cause  whicli  raises  blood- pressu.re  ^ga^tric 
digestion,  mental  exertion,  or  excitement). 

On  the  other  hand,  some  pains  are  made  worse  by  rest;  for  examiile, 
all  types  of  haljit  pains,  to  which  1  shall  refer  more  in  detail  in  the  next 
section.  The  pains  of  chronic  joint  troubles  are  worse  immediately  after 
rest,  when  the  patient  attem))ts  to  moxe  his  stiffened  joints. 


28  DIFFERENTIAL   DIAGNOSIS 

The  effect  of  jolting,  as  in  riding  on  a  rough  road  or  a  rough-gaited 
horse,  is  traditionally  associated  with  an  increase  of  the  distress  pro- 
duced by  stone  in  any  part  of  the  urinary  tract.  Doubtless  this  is  a  true 
observation,  but  there  are  many  exceptions  to  the  rule. 

Aggravation  of  any  pain  by  the  taking  of  food  properly  inclines  us 
to  believe  that  the  pain  is  produced  in  the  stomach  (gastritis,  gastric 
ulcer,  gastric  cancer,  gastric  neurosis).  Many  intestinal  pains,  however, 
are  likewise  produced  or  increased  when  food  enters  the  stomach. 
Thus  the  sufferings  due  to  enteritis  and  to  chronic  intestinal  obstruc- 
tion are  often  much  worse  immediately  after  a  meal.  It  appears  to 
be  true,  moreover,  that  pain  due  to  gall-stones,  and  even  to  chronic 
appendicitis,  may  be  set  agoing  by  the  presence  of  food  in  the 
stomach.  I  have  already  referred  to  the  excitement  of  anginoid  pain 
through  the  rise  of  blood-pressure  produced  by  the  act  of  digestion. 
Possibly  an  accompanying  gaseous  distention  may  help  to  call  out  the 
attack. 

Relief  of  pain  by  food  is  characteristic  of  peptic  ulcer  and  of  hyper- 
chlorhydria,  as  well  as  of  the  vaguer  gnawings  due  to  hunger. 

Many  types  of  muscular,  articular,  and  neural  pains  are  subject 
to  aggravation  as  the  result  of  various  meteoric  conditions,  of  which  we 
understand  all  too  little.  It  cannot  be  questioned,  I  think,  that  the 
muscular  pains  involved  in  lumbago  and  stiff  neck  are  more  apt  to  be 
present  in  damp,  rainy  weather,  such  as  occurs  in  the  spring  and  fall, 
than  in  dry  heat  or  dry  cold.  The  persons  who  can  foretell  a  storm  by 
the  disagreeable  sensations  in  the  neighborhood  of  diseased  joints  are 
very  numerous,  but  I  have  never  been  able  to  associate  this  form  of 
prophecy  with  any  one  type  of  disease.  I  am  also  convinced  that  the 
approach  of  a  thunder-storm  may  precipitate  a  headache  not  only  in 
those  predisposed  to  migraine,  but  in  other  sensitive  persons.  Whether 
this  is  due  to  barometric,  to  electric,  or  to  quite  unknown  conditions 
I  am  unable  to  say.  Alany  of  my  patients  have  noticed  that  their 
headaches  are  more  apt  to  occur  on  especially  bright,  bracing  days, 
when  the  air  is  unusually  clear. 

Relief  by  vomiting  docs  not  prove  that  the  disease  is  of  gastric  origin. 
Intestinal  pain,  biliary  colic,  renal  colic,  and  the  sufferings  of  duodenal 
ulcer  may  also  be  relieved  by  emesis. 

Relief  by  heat  or  by  cold  cannot  be  predicted  for  any  variety  of 
jjains.  The  same  disease  in  different  individuals  may  be  assuaged  now 
by  the  one  now  by  the  other  agencies.  It  is  wholly  a  matter  of  experi- 
mentation. But  in  my  experience  most  of  the  pains  which  cold  relieves 
are  more  completely  and  more  permanently  abated  1)y  heat. 


PAIN 


29 


HABIT  PAINS 
The  term  is  a  misleading  one,  and  needs  more  explanation  than  the 
fact.     The  genesis  of  the  latter  may  be  described  as  follows: 

(a)  Some  exciting,  terrifying,  or  mortifying  event  draws  the  patient's 
attention  to  a  certain  part  of  his  body — the  cardiac  region  or  the  pharynx, 
for  example.     Then — 

(b)  As  the  microscope  discovers  bodies  invisible  to  the  unaided  eye, 
so  the  patient's  focused  and  concentrated  attention  discovers  sensa- 
tions due  probably  to  some  of  the  physiologic  changes  occurring  normally 
in  the  part  to  which  attention  has,  unfortunately,  been  directed.  These 
changes  go  on  normally  without  producing  any  sensation  noted  by  the 
brain.  But  when  the  brain  is  sensitized,  especially  in  relation  to  the  part 
attended  to,  even  the  heart-beat  may  be  felt  as  painful,  or  the  normal 
blood,  lymph,  and  nerve-currents  of  the  pharynx  may  be  magnified 
into  painful  events. 

(c)  The  "set"  of  attention  produced  by  habit  keeps  the  brain  "on 
edge,"  keyed  up  to  perceive  the  slightest  glimmer  of  sensation,  such  as 
we  ordinarily  disregard. 

(d)  Finally,  some  actual  disturbance  of  the  function  of  the  part 
may  follow  this  almormal  interference  of  consciousness  in  acti\ities 
which  should  be  subconscious.  The  heart-beat  becomes  irregular; 
the  pharynx  secretes  abnormally.  This  redoubles,  of  course,  the 
patient's  alarmed  concentration  upon  the  part,  and  so  a  vicious  circle 
is  established. 

Such  a  circle  is  broken,  and  the  diagnosis  of  habit  pain  confirmed 
when  we  succeed  in  switching  off  the  patient's  attention  u])on  other 
subjects — and  thus  making  him  forget,  at  any  rate  for  a  time,  his  habitual 
sufferings. 

THEORIES   REGARDING   THE   PRODUCTION   OF  PAIN 
I  wish  to  refer  briefly  to  the  beliefs  of  McKenzie  and  Head,  also  to 
those  of  J.  Pal,  regarding  the  means  whereby  pain  is  produced  under 
certain  conditions. 

To  James  McKenzie^  and  to  Henry  Head-  we  owe  the  elaboration 
of  a  theory  whereby  pain  and  cutaneous  hyperesthesia  are  viewed  as 
associated  manifestations  of  morbid  irrital)ility  in  one  or  another  group 
of  spinal  ganglion-cells.  According  to  their  theory,  this  irritability 
is  due  to  impulses  transmitted  from  a  diseased  organ,  which,  though 
7!ol  itself  the  seat  of  j)ain,  yet  causes  in  the  corrcs])on(ling  ?i)inal  scgnunt 

*  Jamos  McKcnzi<>,  Symptoms  and  their  Inlcrpretatinn,  Shaw  am!  S.ms,  Lonii^n,  iooq. 
-llenrv   Head,    On    ])isturl>anccs  of  Sensation,  Brain,    iSy3,  vol.   .xvi,  p.  i;    alsi  in 
6ul>sc"([Ucnt  numbers,  1S94,  1S96,  iqoo,  etc. 


30  DIFFERENTIAL  DIAGNOSIS 

a  disturbance  which  is  transferred  thence  to  the  periphery  of  the  body, 
and  there  recognized  by  the  individual  as  pain  in  a  place  often  far  distant 
from  the  organ  diseased. 

Thus  these  writers  account  for  the  umbilical  pain  experienced  in 
intestinal  obstruction,  no  matter  where  the  stoppage  occurs,  by  supposing 
that  all  parts  of  the  intestine  are  represented  in  the  cord  by  the  same 
spinal  segment,  and  that  the  umbilical  region  is  the  seat  of  centrifugal 
impulses  from  that  center,  resulting  in  cutaneous  hyperesthesia,  as  well 
as  pain. 

The  best  confirmation  and  exemplification  of  this  theory  are  seen  in 
the  so-called  radiations  of  the  pain  known  as  angina  pectoris,  and  in  the 
similar  radiations  from  the  site  of  biliary  colic.  It  is  difficult  to  account 
for  the  arm  pains  of  angina  and  the  shoulder  pains  of  gall-stone  disease 
on  any  other  hypothesis,  and  if  all  other  types  of  pain  could  be  traced 
with  similar  accuracy  to  a  spinal  segment,  rather  than  to  an  organ 
directly  underlying  the  painful  spot,  the  theory  of  McKenzie  and  Head 
would  deserve  our  unqualified  assent.  In  point  of  fact,  however,  the 
two  examples  given  above  are  almost  the  only  ones  in  w^hich  the  theory 
is  clearly  verifiable.  The  pain  of  appendicitis,  of  pleurisy,  most  kid- 
ney pains  and  splenic  pains  do  not  well  accord  with  the  tneory,  and 
the  zones  of  cutaneous  hyperesthesia  which  are  essential  to  the  con- 
firmation of  their  theory  have  seldom  been  found  by  other  observers. 
In  spite  of  my  profound  respect  for  the  originators  of  this  theory,  I  have 
been  unable  to  apply  it  successfully  in  clinical  work,  except  in  the  two 
diseases  just  referred  to,  and  in  the  localization  of  spinal  lesions. 

More  useful,  on  the  whole,  is  the  book  on  Gefasskrisen^  in  which 
Pal  elaborates,  upon  the  basis  of  careful  observation,  both  at  the  bed- 
side and  at  the  dead-house,  a  theory  of  the  origin,  not  of  all  pains,  but  of 
certain  paroxysmal  types  of  suffering  associated  especially  with  the  vessels 
of  the  brain,  the  heart,  and  the  kidney,  but  to  a  lesser  extent  with  those 
of  the  intestine  and  of  the  extremities.  He  supposes  that  arterial  spasm 
(favored  and  prepared  for  by  arteriosclerosis,  by  uremia,  by  lead-poison- 
ing, and  by  the  nerve  lesions  of  tabes)  is  the  cause  of  a  large  group  of 
pains,  paralyses,  and  other  fimctional  disturbances  which  had  never  before 
been  brought  together  under  any  single  explanation.  Taking  lead-poison- 
ing as  an  impressive  example  of  the  theory,  he  points  out  that  we  have 
here  a  notable  rise  of  blood-pressure,  associated  sometimes  with  cerebral 
crises  (headache,  convulsions,  coma),  often  with  abdominal  crises 
(lead  colic),  and  occasionally  with  anginoid  seizures.  In  arteriosclerosis 
we  have  likewise  cerebral,  abdominal,  and  cardiac  crises,  and,  in  addi- 

^  J.  Pal,  Ge/asskrisen,  Leipzig,  1905. 


PAIN 


31 


tion  to  these,  well-marked  peripheral  crises  (intermittent  claudication). 
In  uremic  and  eclamptic  poisoning  we  have  likewise  cerebral  and  ab- 
dominal crises.  In  tabes  dorsalis  the  abdominal  crises  are  the  most 
familiar. 

In  all  these  affections  postmortem  examination  may  demonstrate 
that  there  is  no  gross  lesion,  such  as  cerebral  hemorrhage  or  throm- 
bosis, coronary  occlusion,  or  blocking  of  a  peripheral  artery.  Indeed, 
the  arteries  and  the  surrounding  tissues  may  appear  almost  or  quite 
normal  postmortem.  It  is  natural,  therefore,  to  assume  some  functional 
change,  such  as  spasm,  to  account  for  the  pain,  paralysis,  and  other 
functional  changes  recognized  at  the  bedside.  In  favor  of  the  hypothe- 
sis of  vascular  spasm,  or  Gefasskrise,  are  two  considerations : 

(a)  A  rise  of  blood-pressure  has  many  times  been  demonstrated  by 
Pal  before,  as  well  as  during,  the  crisis.  This  h}-pertension  cannot 
be  accounted  for  as  a  result  of  pain,  since  in  many  of  Pal's  cases  it  pre- 
ceded the  pain.  He  has  found  it  in  the  gastric  crises  of  tabes,  as  well  as 
in  the  uremic,  saturnine,  and  arteriosclerotic  cases. 

{h)  During  an  attack  of  transient  blindness  occurring  in  a  patient 
who  had  been  subject  to  various  other  ''crises,"  ophthalmoscopic  ex- 
aminations showed  a  high-grade  spasm  or  contraction  of  the  retinal 
arteries. 

So  much  for  the  theory  and  the  e\idence  on  which  it  is  based.  It 
seems  to  me  a  good  working  hypothesis  as  an  explanation  of  many 
of  the  transient  amauroses,  aphasias,  monoplegias,  hemiplegias,  and 
headaches  associated  with  chronic  nephritis.  Like  other  theories, 
it  is  to  be  tested  partly  by  what  it  enables  us  to  discover.  Like  the 
atomic  theory,  it  may  lead  us  to  perceive  and  so  to  fill  in  certain  gaps, 
such  as  appear  in  the  following  talkie: 

CRISES 


Cerebral. 

+ 

C 

irdiac. 

Abdominal. 

-f 

Peripheral. 

+ 

Pul 

nionary. 

+  ? 

I^iOTiKeal 

I. 

Arteriosclerosis 

+ 

— 

2. 

Nephritic    hyj)ertcn- 

sion  ("uremia") 

+ 

-f- 

+  ? 

- 

_|_  p 

- 

V 

Tabes  dorsalis 

- 

- 

+ 

_l- 

- 

+ 

4- 

Plumbism 

+ 

+  ? 

+ 

- 

- 

- 

I  may  here  acknowledge  my  deep  indebtedness  to  RudoU'  Schmidt's 
book  on  Pain,*  which  has  guided  and  confirmed  my  own  obstr\a- 
tions  on  many  points. 

'Pain — its  Causation  and  T)ia<^nostic  Siqnifu  anc  c,  1)\-  Kuiiolf  Sdiinidt;  translated 
by  Karl  M.  Vogel  and  Hans  Zinsser,  J.  B.  Liiipincoit  Comj.anv,  190S. 


CHAPTER    II 
HEADACHE 

I.  GENERAL  CONSIDERATIONS 

In  discussing  this,  probably  the  commonest  of  all  symptoms,  I  shall 
exemplify  by  cases  only  such  causes  as  are  likely — (a)  to  be  complained 
of  by  the  patient  as  his  leading  symptom,  and  (b)  to  occasion  diagnostic 
difficulties.     Others  will  be  briefly  mentioned  here. 

1.  Anemia  of  any  type — pernicious,  chlorotic,  posthemorrhagic— 
is  now  and  then  accompanied  by  headache,  usually  as  a  minor  symptom. 
It  is  noteworthy,  however,  that  intense  anemia  often  persists  for  months 
without  producing  any  headache  whatever.  It  may  well  be  doubted 
whether  anemia  is  ever  in  itself  the  cause  of  headache.^ 

2.  Fatigue^  hunger,  and  bad  air  often  produce  a  headache  (perhaps 
due  to  the  circulation  of  ''fatigue  poisons")  whose  cause  is  made  obvious 
by  its  disappearance  after  rest,  food,  and  fresh  air. 

3.  Poisons,  such  as  alcohol,  morphin,  and  lead.  Except  after  a 
drinking  bout,  I  have  never  known  a  patient  whose  chief  complaint,  as  a 
result  of  any  of  these  poisons,  was  headache.  Other  symptoms  usually 
occupy  the  foreground. 

4.  Arteriosclerosis. — It  has  long  been  stated  in  medical  lectures  and 
text-books  that  the  headaches  of  elderly  persons  are  frequently  caused  by 
arteriosclerosis.  My  own  experience,  however,  coincides  entirely  with 
that  of  Thomas,  of  Walton,  and  of  Paul,^  who  deny  any  such  asso- 
ciation. In  my  experience,  it  is  only  when  the  kidney  is  extensively 
involved  and  blood-pressure  thereby  raised  that  headache  results  from 
arteriosclerosis. 

5.  Indigeslion  and  Constipation.— Gsistric  stasis,  arrested  digestion, 
and  the  resulting  abnormal  fermentation  of  food  often  lead  to  a  head- 
ache which  needs  no  further  mention  here.  The  patient  can  usually 
make  the  diagnosis  for  himself.     The  same  is  often  true  of  the  headaches 

^  Of  697  cases  of  pernicif)us  anemia  studied  by  me,  300  had  no  headache  at  any  time. 
See  Osier's  Modern  Medicine,  vol.  iv,  p.  622. 

^  Walton  and  Paul,  Jour.  Amer.  Med.  Ass<jc.,  190S;  Thomas,  Osier's  Modern  Medicine, 
vol.  vii,  p.  336. 

32 


Causes  of  Headache 


1.  FATIGUE,   BAD  AIR,  AND   HUNGER 

2.  CONSTIPATION  AND  INDIGESTION  ("BILIOUS- 

NESS"! 


3.  ALCOHOL  (THE  "DAY  AFTER"  HEADACHE) 


CASES    TOO    MANY    AND    TOO 
VAGUELY  ENUMERABLE    FOR 

4.  EYE-STRAIN     AND     INTRINSIC     DISEASES     OF  graphic  representation. 

THE  EYE 

5.  INFECTIOUS  DISEASES  (ONSET) 

6.  MENSTRUATION 


7.  PSYCHONEUROSES 

8.  NEPHRITIS 

9.  MENINGITIS 

10.  SINUSITIS 

11.  TRIGEMINAL     ^ 

NEURALGIA  I 

12.  "  INDURATIVE" 

13.  MIGRAINE 

14.  BRAIN  TUMOR 

15.  SYPHILITIC  \ 

PERIOSTITIS'  I 

16.  UNKNOWN   CAUSE 


1039 
602 
172 
157 

117 

89 

89 
46 

16 

619 


'    TiK-  (li:iL;iio>is   ot'    iiilrarranial    >y]>!iilis   .-cfiii-   to   me  still    >o   uncertain    that    1    Ikim 
not   incliiiied   it   here. 


HEADACHE 


35 


resulting   from   constipation,   miscalled    "lithemia,"    "biliousness,"   or 
"torpid  liver." 

A  remarkable  feature  of  this  type  of  headache  is  its  swift  disappear- 
ance, in  certain  cases,  after  defecation.  From  several  very  intelli2;ent 
patients  I  have  heard  repeatedly  the  story  of  a  headache  that  disap- 
peared, wholly  or  mostly,  within  a  few  minutes  of  the  time  of  defeca- 
tion. This  is  hard  to  reconcile  with  any  chemical  theory  regarding  the 
origin  of  such  a  pain. 

6.  Many  common  infections — rhinitis,  tonsillitis,  the  exanthemata, 
etc. — are  often  accompanied  by  headache,  which,  however,  is  rarely 
the  patient's  chief  complaint.  There  are  other  infections — examples  of 
which  will  be  given  below — which  cause  so  sc\ere  and  persistent  a  head- 
ache that  it  becomes  the  "presenting  symptom." 

7.  The  headache  sometimes  accompanying  otitis  media  and  other 
forms  of  aural  disease  gets  its  recognition,  in  the  vast  majority  of  cases, 
from  the  concurrent  aural  symptoms. 

8.  Menstruation  is  often  preceded  or  followed,  less  often  accompanied, 
by  headache  the  exact  origin  of  which  is  very  obscure. 

9.  Trigeminal  neuralgia,  with  or  without  the  paroxysms  and  ST)asms 
of  tic  douloureux,  ])resents,  as  a  rule,  no  serious  difiicultics  in  diagnosis, 
and  will,  therefore,  not  l)e  further  mentioned  here.  Mild  types  may 
originate  in  dental  caries  or  other  peripheral  irritations.  The  sc\erer 
forms  appear  to  be  due  to  changes  in  the  Gasscrian  ganglion. 

10.  Insolatimi,  with  or  without  actual  sunstroke,  has  often  been 
listed  am.ong  the  causes  of  headache.  In  my  experience,  however,  there 
is  usually  a  large  neurasthenic  element  in  these  cases,  and  the  history 
of  insolation  is  often  vague  and  forced. 

11.  Adolescence  is  fref|uently  associated  with  a  headache  for  which  no 
local  cause  can  be  found.  \\'e  connect  such  headaches  vaguely  with 
adolescence,  because  they  pass  ofl"  with  the  end  of  that  ])eri()d. 

12.  Cerebral  concussion — as  in  a  foot-ball  game — is  a  common  cause 
of  headache,  which  usually  ])rcsents  no  diagnostic  difficulties. 

13.  Indurative  Ileadaclie. — "This — j)rol)ably  the  most  J'ru/utiit 
form  of  headache — seems  to  be  unknown  to  the  majority  of  ])hysicians, 
ahhough  it  has  been  described  in  text  books  for  decades"  (I'-dinger,  in 
Die  Deutsche  Klinik'). 

The  term  ^^ indurative'''  ex])resses  an  attemj)t  to  characterize  the 
malady  without  committing  oursebes  to  anv  theorv  ri'garding  its  cause 
or  morbid  anatomy.      In  some  of  tlie  okler  l)ooks  it   is  retV'rriHi   to  as 

' 'IVanslatcd  under  title  of  MiKiern  ("linieal  Medicine,  in  the  \i'himr"ii  Pi^eaMsnf 
the  N('rv<ju,s  Svsteni,  p.  803,  Appleton,  igoS. 


36 


DIFFERENTIAL   DIAGNOSIS 


"rheumatic  headache."  Its  distinguishing  feature  is  the  presence 
of  painful  "indurations"  near  the  insertions  of  the  muscles  at  the 
occiput.  Bits  of  the  trapezii,  sternocleidomastoids,  scaleni,  or  splenii 
become  sensitive,  uneven,  and  nodular,  "as  if  something  were  deposited 
in  the  substance  of  the  muscle."     (See  Fig.  i.) 

Pain  which  is  chiefly,  but  not  exclusively,  occipital  is  associated  with 
these  "indurations,"  and  disappears  when  they  are  removed  by  mas- 
sage.    It  is  on  this  account  that  the  disease  is  so  much  better  known  to 


Fig.  I. — The  points  upon  which  indurations  are  most  frequently  found  (Edinger). 

the  masseurs  and  to  the  physicians  who  ha\"e  studied  and  practised 
massage  than  to  tlie  medical  ])rofession  at  large.  Writers  on  massage 
do  not  hesitate  to  speak  of  the  "indurations"'  as  foci  of  ''chronic  myo- 
sitis,^' but  there  are,  so  far  as  I  know,  no  histologic  examinations  on 
which  we  can  base  such  a  term.  PMinger  ^  ap])arently  considers  the  con- 
dition a  neuralgia.  Swelling  of  the  neighboring  lymph-glands  and  of 
the  cervical  sympathetic  ganglia  is  mentioned  b}-  some  writers. 

The  sensitiveness  to  touch  extends  to  llie  ajwneuroses  o\"er  the  skull, 

*  P.  S6t  in  the  volume  above  cited. 


HEADACHE 


37 


to  the  vertex  and  even  to  the  frontal  region;  also  down  along  the  outline 
of  the  trapezius  on  the  shoulder.  In  this  as  in  many  other  respects  it 
resembles  "lumbago"  and  ''stiff  neck." 

The  disease  is  often  referred  to  as  "rheumatic,"  because  it  seems  in 
some  cases  to  follow  exposure  to  cold  and  wet,  e.  g.:  "A  few  days  before 
the  appearance  of  the  symptoms  he  had  been  overtaken  l^y  a  hailstorm 
while  riding  a  bicycle."  To  some  these  statements  still  carry  convic- 
tion, c.  g.,  to  Edinger,  who  says:  "It  is  certain  that  refrigeration  may 
produce  the  disease." 

I  have,  I  regret  to  say,  no  cases  in  my  own  experience  which  exem- 
plify this  disease.  I  have  referred  to  it  here  because  it  seems  to  me  to 
deserve  more  careful  study  by  clinicians  and  because  of  Edinger's 
statement,  based  on  his  extensive  experience  at  the  Neurological  Institute 
in  Frankfurt-am-]\Iain,  that  it  is  probably  the  most  frequent  form  of 
headache,  and  that:  "The  examination  of  the  insertions  of  the  muscles 
should  never  be  neglected  in  any  case  of  headache." 

14.  Vasomotor  Headaches. — Though  vasomotor  disturbances  may 
occur  in  various  types  of  headache,  esi)ccially  in  migraine,  there  remains 
a  group  of  cases  in  which  only  the  vasomotor  trouble  (vasoparalysis 
and  vasodilatation)  is  discoverable  as  cause.  These  patients  have  ^■ery 
red  faces  in  the  attack,  and  usually  show  reddish  blotches  or  stride  over 
the  rest  of  the  body.  The  diagnosis  is  made  1)y  the  presence  of  the  above 
signs  and  by  exclusion  of  all  other  known  causes. 

2.  POSITION  AND  NATURE  OF  THE  HEADACHE 

(i)  ]Many  text-books  map  out  the  surface  of  the  skull  witli  s])ccial 
"headache  areas,"  reminding  one  of  a  ])hrcnologic  ma]),  l)ut  in  my 
experience  there  is  not  often  much  to  be  learned  from  the  position  of  a 
JicadacJic.  Ocular  headaches  often  ])egin  or  center  near  the  eyes;  ])ains 
due  to  otitis  media  often  sjjread  from  an  initial  focus  near  the  ear. 
Inllammations  of  the  antrum  or  frontal  sinus  cause  ])ain  o\cr  the  affected 
ca\ity.  The  ])ain  of  syphilitic  ])eriostitis  corres])onds  with  the  ]i()sition 
of  the  lesion.  ^Migraine,  with  its  uniUiteral  distribiUion,  and  triireirinal 
neuralgia  ]ia\'e  also  a  t}"j)ical  distribution. 

On  tlie  other  hand,  ocular  and  a.ural  lieadaclie  is  often  not  tluis 
loeah'/.ed,  and  the  ])ain  (hie  to  an\'  of  tlie  other  famihar  causes  lureniia. 
infection,  l)rain  tumor,  (•onstipati<»n,  nienstrualion,  neuvastlienia'  mav 
1)e  in  any  ])art  of  tlie  head,  and  is  ofti-n  unilateral,  so  as  to  be  ini-'.alcr 
for  migraine. 

(2)  The  /•/;/(/  of  ])ain  is  likewise  of  \'erv  little  siuniiu-anct' :  ihrol'bing. 
d'vill.  burning,  l)oring  headaches  are  encountered  iii  all  >(>rl>  ot  dij-rax--. 


^8  DIFFERENTIAL   DIAGNOSIS 

A  sense  of  constriction  and  pressure  is  mentioned  by  many  patients  of 
the  psychoneurotic  group,  especially  if  they  have  been  to  France  and 
have  been  told  that  they  have  a  "tete  en  casque." 

(3)  The  severity  of  headache  is  probably  greatest  in  organic  diseases 
of  the  brain  or  periosteum  (cerebral  tumor,  meningitis,  syphilitic  perios- 
titis), in  the  paroxysms  of  tic  douloureux,  and  in  those  of  migraine. 

(4)  Chronic  headaches,  sometimes  lifelong,  are  associated  with  all 
the  psychoneuroses  (neurasthenia,  hysteria,  psychasthenia),  and  are 
sometimes  present  without  any  discoverable  cause.  They  are  often 
referred  to  the  ''base  of  the  brain"  (meaning  the  nape  of  the  neck). 
Blows  on  the  head,  sunstroke,  arsenical  poisoning,  and  all  sorts  of 
"reflex"  disturbances  (pelvic,  ocular,  gastro-intestinal)  are  often  vainly 
invoked  as  causes,  and  the  term  "constitutional"  is  often  attached  to 
such  pains,  but  a  frank  confession  of  our  ignorance  seems  to  me 
better. 

(5)  The  time  of  day  markedly  influences  some  headaches;  those 
associated  with  frontal  sinus  disease  often  begin  at  the  same  hour  each 
morning,  last  a  certain  time,  and  pass  off.  This  is  also  true  of  the  psy- 
choneurotic group,  but  the  time  of  seizure  and  of  relief  is  much  less 
accurately  recurrent. 

Headaches  due  to  syphilis,  to  brain  tumor,  and  to  uremia  are  often 
worse  at  night,  but  syphilis  has  no  monopoly  of  this  characteristic. 

3.  TWO  TRADITIONAL  FALLACIES  ABOUT  HEADACHE 

(a)  The  belief  that  physiologic  and  pathologic  states  of  the 
female  generative  organs  often  produce  headache  is  widespread.  Text- 
books, such  as  Butler's,  list  dysmenorrhea,  "  uterine  disease,"  disease 
of  the  ovaries,  and  even  of  the  bladder  (!)  as  causes  of  headache.  No 
proper  justification  for  these  ideas  has  yet  been  attempted,  so  far  as  I 
am  aware.  Headache  is,  of  course,  exceedingly  common  in  menstru- 
ation, but  so  it  is  in  eclampsia;  yet  no  one  to-day  connects  the  eclamptic 
headache  in  any  direct  way  with  the  condition  of  the  uterus.  Toxemia 
of  the  puerperium,  toxemia  of  the  menstrual  period,  is  a  much  more 
plausible,  though  not  a  demonstrable,  hypothesis.  (For  further  evidence 
on  this  point  see  p.  8;^.) 

(b)  "  Lithemia  "  and  "  rheumatism  "  are  also  frequently  invoked  to 
explain  headache.  Neither  word  is  defined  by  those  who  use  them  in 
this  connection.  '' Lithemia  "  means  constipation  and  the  indigestion 
of  lazv,  gluttonous  people,  conditions  which  certainly  do  produce  head- 
ache.    (See  p.  ^5.) 


HEADACHE 


39 


"  Rheumatic  headaches  "  refer  usually  to  the  type  associated  with 
''stiff  neck  "  and  indurations  in  the  bellies  of  muscles  attached  to  the 
occiput  or  the  temporal  region.      (See  above,  p.  36.) 

There  seems,  however,  no  sufficient  reason  for  continuing  the  tradi- 
tion which  applies  the  word  "rheumatism"  to  such  lesions. 

4.  IMPORTANT  TESTS 

The  following  tests  should  be  made  in  all  puzzling  cases: 

1.  Thorough  examination  of  the  eyes  (including  retinoscopy) , 
the  pupil,  and  the  testing  of  intra-ocular  tension  (glaucoma). 

2.  Temperature  record  (infections). 

3.  Blood-pressure  measurement  (nephritis,  tumor). 

4.  Urinalysis  (albumin,  sugar,  acetone). 

5.  Palpation  of  the  insertion  of  the  nape  muscles  at  the  occiput, 

6.  Examination  of  the  nose  and  its  accessory  sinuses. 

In  the  history,  the  following  clues  should  be  attended  to: 

(a)  Is  the  headache  of  paroxysmal  occurrence  and  fixed  duration 
(usually,  twelve  to  twenty-four  hours),  accompanied  by  disturbances  of 
vision  and  great  prostration  (migraine)? 

(b)  Is  the  history  that  of  a  psychoneurosis? 

(c)  Does  the  pain  recur  at  precisely  the  same  hour  each  day? 

Case  1 

A  married  woman  of  forty-two  consulted  me  March  17,  1004,  for  long- 
standing headaches  which  had  been  present,  off  and  on,  during  the  last 
live  years,  since  an  attack  of  what  was  called  ''grip,''  followed  by  deaf- 
ness and  ringing  in  the  left  ear.  The  ])atient  li\es  in  a  very  malarious 
part  of  a  specially  malarious  suburb  of  Boston,  but  has  ne\er  had  the 
disease,  so  far  as  she  knows. 

For  the  past  year  the  headaches  have  been  much  more  se\ere.  and 
have  come  with  especial  frequency  at  night,  together  with  a  burning 
sensation  over  the  left  side  of  the  head,  and  to  some  extent  over  the  entire 
body,  and  accompanying  this  burning  sensation  she  feels  chilly,  but  the 
temj)erature  has  ne\er  been  taken.  I'he  menopause  occurred  a  year  ago. 
and  since  that  time  she  has  noticed  that  she  is  getting  stouter,  tliat  her 
skin  is  very  dry,  harsh,  and  sallow,  with  scarcely  any  j>er>j)iration.  and 
that  her  lips  look  bluish.  Pain  and  the  sense  of  coldness  are  often  telt 
in  the  lower  left  axilla.  Each  winter  she  feels  the  eold  more  and 
more. 

Some  months  airo  she  noticed  edema  of  the  feet  and   fare:  at   the 


40  DIFFERENTIAL   DIAGNOSIS 

present  time  there  is  none,  but  she  gets  out  of  breath  upon  the  sHghtest 
exertion,  and  her  heart  then  beats  violently,  rapidly,  and  irregularly. 
Her  urine  is  thick,  dark,  offensive,  and  at  times  its  passage  is  followed 
by  vesical  tenesmus.  The  headache  often  wakes  her  in  the  night,  and  as 
soon  as  she  wakes  she  has  to  pass  water,  which  gives  relief  to  the  head- 
ache. She  thinks  she  passes  more  urine  at  night  than  in  the  daytime. 
She  is  very  irritable,  and  has  much  twitching  and  quivering  of  the  Hps. 
Her  only  child  was  born  ten  years  ago,  and  died  within  the  first  year. 

On  examination  the  hands  and  lips  were  of  a  dark,  slaty-blue  color, 
yet  quite  warm.  The  face  showed  a  yellow  pallor,  the  total  effect  being 
that  often  seen  under  the  Cooper  Hewitt  mercury  light,  such  as  is  used 
in  automobile  garages.  The  heart  was  negative,  save  for  a  slight  sys- 
tolic murmur  at  the  base.  The  lungs  showed  nothing  abnormal.  The 
edge  of  the  spleen  was  easily  felt  on  full  inspiration.  Its  consistency 
seemed  increased.  The  abdomen  was  otherwise  negative.  The  tem- 
perature was  99.2°  F.  at  5  p.  m.  The  urine,  save  for  high  color  and 
other  evidences  of  concentration,  showed  no  abnormality. 

Discussion. — -The  possibilities  which  were  first  considered  in  this 
case  included  cardiac  disease,  myxedema,  malaria,  and  another  presently 
to  be  mentioned.  The  diagnosis  of  the  attending  physician  was  "some 
queer  kind  of  heart  disease,"  but  on  examination  I  could  lind  no  heart 
disease,  queer  or  otherwise,  although  the  breathlessness  and  cyanosis 
made  it  natural  to  search  for  a  cardiac  lesion. 

Myxedema  was  suggested  by  the  cutaneous  changes  and  the  sensi- 
tiveness to  cold,  but  on  cross-questioning  neither  of  these  two  character- 
istics was  at  all  well  marked,  and  there  were  no  mental  changes,  no  sub- 
normal temperature  and  no  special  alteration  in  the  physiognomy 
except  as  regards  the  extraordinary  coloration  before  mentioned.  It 
was  easily  made  clear  that  this  cyanosis  did  not  depend  upon  any  disease 
of  the  heart  or  lungs.  The  enumeration  of  the  red  cells  showed  but 
4, 1 8c, 000,  ])roving  that  the  color  of  the  lijjs  was  not  due  to  polycythemia. 
There  was  nothing  in  the  symptomatology  nor  in  the  gross  character- 
istics of  the  feces  to  suggest  a  cyanosis  of  intestinal  origin,  nor  did  the 
coloration  a])pear  to  he  of  the  vasomotor  tvj^e,  so  often  seen  in  neurotic 
and  hysteric  [)atients.  There  was  no  ebb  and  !low  about  it,  no  varia- 
tion in  the  tint  from  hour  to  hour,  nor  from  day  to  da  v.  By  rough  tests 
tliere  ^\■as  no  notable  deafness  and  no  mastoid  tenderness. 

After  excluding  the  causes  above  referred  to.  it  was  natural  to  think 
of  methemoglobinemia,  such  as  is  often  produced  by  overdose  of  head- 
ache j)Owders  containing  acetiinilid.  Her  attending  ph}"sician  had  given 
her  no  such  powders  nor  any  diug  l^elonging  to  the  group  {)rone  to  pro- 


HEADACHE 


41 


duce  methemoglobinemia,  but  on  questioning  the  patient  I  learned 
the  following  facts:  For  the  last  five  years  she  had  been  taking  headache 
yx)wders  in  increasing  numbers.  Her  husband  obtained  a  box  of  them 
from  the  local  druggist  once  or  twice  a  week,  and  by  calculation  it 
appeared  that  she  had  averaged  ico  grains  a  week  for  some  months, 
great  relief  being  thus  obtained  for  the  headache. 

A  drop  of  her  blood  soaked  into  the  bibulous  paper  of  the  'rak|\ist 
hemoglobin  scale  produced  a  chocolate-brown  stain,  quite  incom])arable 
with  any  of  the  hemoglobin  tints  of  the  scale.  Spectroscoj)ic  examina- 
tion showed  the  familiar  spectrum  of  methemoglobin. 

Outcome. — The  patient  was  ordered  at  once  to  stop  the  headache 
powders  and  to  take  no  medicine  containing  acetanilid  or  any  member 
of  that  group.  May  3d  she  reported  that  her  headaches  were  much  less, 
her  sleep  and  breathing  much  better,  and  her  sensitiveness  to  cold  much 
less  troublesome.  She  was  still  weak  and  pale,  but  her  appetite  was 
much  impro\'ed,  and  she  had  gained  eight  pounds  since  March  17th. 

January  26,  1907,  the  attending  physician  writes  me:  "A  year  after 
you  saw  her  the  general  condition  was  much  better,  although  she  occa- 
sionally had  severe  headaches.  The  color  of  the  l^lood  was  imj)ro\ing, 
but  at  the  time  of  the  last  examination  which  I  made,  a  year  after  you 
saw  her,  blood  still  showed  a  tinge  of  brown." 

Diagnosis. — Methemoglobinemia. 

Case  2 

A  longshoreman  of  thirty-six  v,as  first  seen  March  8,  1904.  The 
patient  has  been  in  the  habit  of  taking  three  glasses  of  whisky  a  day. 
He  had  gonorrhea  at  twenty-six,  and  chancre  twehe  years  ago.  fi)lloued 
by  sore  throat,  a  mucous  j^atch,  and  an  eru])tion. 

He  had  tyjihoid  and  pnevnnonia  at  thirty.     Family  history  good. 

For  a  good  ])art  of  the  past  fne  vears  lie  lias  had  frontal  headaclie. 
I>ast  ( )ct()l)er  he  Ijcgan  to  take  potassium  iodic),  but  in  Xoxenibcr 
the  headache  became  worse,  and  a  swelling  ai)i)eare(l  on  the  forelu'ad 
over  the  left  eve.  The  pain  lasted  a  week  and  then  disappeared.  A 
week  ago.  after  being  exposed  to  a  \iolent  draft  on  a  sleeping-ear.  he  IkkI 
a  similar  attack.  This  time  his  exfs  were  closed  by  a  >\\T]lin!.'  ot  the 
lids.  Ilis  forehead  \\as  tcncK'r  and  swolK'n.  csiXH-iallx-  on  tl  c  Ktt.  Now 
he  complains  of  sewre  pain  iii  the  forrliead.  with  s'.'a'lIinL:  aii'l  tcp.iKiru  ->. 

Two  vears  ago  he  had  what  mtiiumI  like  a  similar  pi"o<  {»  :•'.  l!u 
metacarpal  bones  of  the  riglit  hand,  the  hone  lieconiing  i-nlai-gnl  ami 
vvrv  tender.  Ilis  general  e<»n(iition  is  no\'.  In-tter  than  ^i\  iiionih-  a-o. 
lie-  lias  taken   jxitassium  iodid,  but   finds  that  it  make-  !k,e  lain    .'.Mi>r. 


42  DIFFERENTIAL   DIAGNOSIS 

He  has  taken  as  much  as  225  grains  a  day,  but  not  regularly.  His 
appetite  is  good,  his  bowels  regular.  He  has  had  no  symptoms  of 
iodism,  and  feels  perfectly  well  but  for  his  headache. 

On  physical  examination  the  points  mentioned  in  the  history  were 
verified,  and  nothing  else  was  discovered.  The  second  left  metacarpal 
bone  was  much  enlarged  and  irregular  in  outline.  There  were  also 
enlargements  at  the  base  of  the  first  phalanx  of  the  left  index-finger, 
and  a  slight  rounded  prominence  over  an  area  the  size  of  an  egg  above 
the  left  eyebrow.  The  temperature  ranged  between  98°  and  99.5°  F. 
The  leukocytes  were  17,200  at  entrance,  78  per  cent,  of  them  being  poly- 
nuclear.  The  hemoglobin  was  70  per  cent.,  and  the  red  cells  showed 
a  slight  achromia. 

1.  What  further  inquiries  and  examinations  are  likely  to  throw  light 
on  this  case? 

2.  What  inferences  can  be  drawn — (a)  From  the  effect  of  a  draft  on 
the  pain;  (b)  from  the  effect  of  potassium  iodid? 

3.  Why  is  eye-strain  an  unlikely  cause  for  this  headache? 

4.  What  points  against  frontal  sinus  disease? 

5.  What  three  common  chronic  ulcerati\e  processes  involve  the  skin 
and  deeper  tissues  most  frequently. 

Further  inquiry  into  the  past  history  revealed  the  fact  that  he  had 
had  a  chancre  at  twenty-eight,  followed  by  a  rash  and  a  sore  throat, 
with  white  patches  in  his  mouth.  A  Wassermann  test  (not  known  in 
1904)  would  have  helped  toward  diagnosis. 

Probably  the  "effect"  of  the  draft  was  coincidence,  at  most,  an 
exciting  or  favoring  cause.  Many  headaches  miscalled  "rheumatic" 
are  really  syphilitic.  There  is  no  reason  to  believe  that  "rheumatism" 
ever  causes  headache  except  in  acute  infectious  cases.  The  failure  of 
potassium  iodid  is  discussed  below. 

Eye-strain  does  not  often  begin  at  thirty-six  in  a  man  who  uses  his 
eyes  for  such  work  as  a  longshoreman's. 

The  long  duration  of  the  headache  is  against  disease  of  the  frontal 
sinus.     Physical  examination,  however,  must  determine  the  point. 

Three  common  causes  for  chronic  ulcerative  processes  (excluding 
varicose  ulcer)  are:    Syphilis,  tuberculosis,  malignant  disease. 

[The  man  was  seen  in  consultation  by  Drs.  Bowen,  Shattuck.  Fitz, 
Gannett,  A.  T.  Cal)ot,  and  J.  P.  Clark.  All  concurred  in  the  diagnosis 
of  syphilitic  periostitis.] 

Outcome. — The  day  after  entrance  two  distinct  craters  al)out  the 
size  of  a  half-dollar  v/ere  felt  on  the  forehead.  The  headache  was  given 
some  immediate  relief  ])y  10  grains  of  phcnacetin  with  2  of  caffein,  but 


HEADACHE 


43 


sulphonal  and  trional,  lo  grains  each,  were  also  needed  for  sleep.  He 
was  given  inunctions  of  mercury  and  potassium  iodid  grains  lo,  increas- 
ing to  loo.  Black-wash  was  also  a])plied  to  the  forehead,  and  on  the 
twelfth  the  iodid  was  omitted  on  account  of  marked  swelling  of  the  left 
eyelid.  By  that  time  the  swelling  of  the  forehead  was  much  less,  and 
after  omitting  the  iodid,  the  swelling  of  the  eyelid  also  became  normal. 
By  the  fifteenth  of  March  his  symptoms  had  almost  disaj)peared.  Ob- 
viously, the  mercury,  rather  than  the  iodid,  was  what  helped  him.  He 
showed  at  no  time  any  signs  of  salivation. 

In  view  of  the  above  facts  the  diagnosis  of  syphilis  is  not  in  doubt, 
and  needs  no  further  discussion  in  this  case.  The  relation  of  syphilis 
to  headache  seems  to  warrant  us  in  dividing  sy])hilitic  headaches  into 
three  groups: 

(a)  An  acute  infectious  headache,  occurring  at  or  near  the  time  of  the 
roseola,  adenitis,  and  other  "secondary"  lesions. 

{h)  A  chronic  periosteal  headache,  with  or  without  obvious  external 
lesions  on  the  forehead. 

(c)  A  headache  with  symptoms  of  brain  tumor,  due  to  localized  syphil- 
itic processes  within  the  skull,  forming  syphilomatous  tumors  or  causing 
internal  hydroce[)halus. 

The  latter  group  is  of  es|)ecial  importance,  since  they  are  often 
mistaken  for  genuine  brain  tumor,  whence  follow  a  hopeless  ])rognosis, 
a  neglect  of  vigorous  antisyi)hilitic  treatment,  and  much  unnecessary 
suffering.  I  have  three  times  seen  recovery  after  antisy])hilitic  treatment 
in  cases  given  up  to  die  of  brain  tumor.  I'he  only  safe  rule  is:  Give 
mercury  (in  moderate  doses)  and  potassium  iodid  (in  doses  gradually 
becoming  enormous)  in  every  case  presenting  the  signs  and  symptoms  of 
cerebral  tumor. 

The  T)rognosis  is  for  immediate  relief  and  subsecjuent  recurrence 
in  one  or  another  form.  I'he  expectation  of  life  is  much  less  tlian  for 
non-syj)hilitics. 

'J'reatment — mercury  es])ecial]y-  should  ])e  gi\en  at  inlerxals  tor 
life.  I'otassium  iodid  is  needed  only  when  delinite  lesions  are  recog- 
nized. 

Diagnosis. — Syj)hilitic  ])eriostitis. 

Case  3 

A  married  Russian  housewife  of  thirt\--se\en  entered  tlie  li(^-!'ital 
MaN'  17,  i()04.  In  i()Oi  she  had  l)iH'n  in  ihr  surgical  ^^anl^  tor  a  -liir- 
ture  of  tb.c  rectum  of  intlanimatorx-  origin,  for  which  an  inguinal  colo.^- 
tomv  was  done,      .\fler  this  oixTation  >lie  had  no  trouMr  \'.  illi  hci-  I'ov.  els 


44 


DIFFERENTIAL   DIAGNOSIS 


(which  had  been  seriously  constipated) ,  the  inguinal  wound  was  closed, 
and  she  remained  well  until  May  i,  1904,  when  she  began  to  have  pain 
in  the  back  of  her  head,  at  first  mild,  and  relieved  by  "bromo-seltzer,' 
but  for  the  past  week  very  severe  and  extending  over  the  whole  head. 
It  now  lasts  through  the  entire  twenty-four  hours,  and  has  prevented 
sleep  for  the  past  two  nights.  Day  before  yesterday  she  had  an  attack 
of  nausea  and  vomiting.  The  headache  is  so  severe  that  she  wants  to 
jump  through  the  window  and  kill  herself.  She  feels  first  hot,  then 
cold,  sweats  a  great  deal,  especially  at  night,  and  easily  becomes  tired. 
Physical  examination,  including  the  fundus  of  the  eye,  shows  nothing 
abnormal  except  an  inequality  of  the  pupils.  Their  reactions,  however, 
are  normal,  likewise  the  blood  and  urine. 


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Fig.  2. — Chart   of   case  3. 

For  the  first  two  days  her  headache  was  continuous  and  severe, 
despite  lactophenin,  lo  grains,  caffein,  5  grains,  sodium  bromid.  ,^0 
grains,  potassium  iodid,  10  grains,  three  times  a  day.  Compound  jalap 
powder,  i  dram,  and  high  enemas  of  oil  and  suds  were  given  in  the  ho])e 
that  the  headache  might  be  relieved  by  purgation.  In  spite  of  all  these 
remedies  the  headaclie  was  undiminished  at  the  end  of  the  first  week 
in  the  hospital. 

Discussion. — -Xo  certain  diagnosis  can  be  made  in  this  case.  Tlie 
relief  following  potassium  iodid  may  well  ht  a  coincidence,  for  many 
headaches  of  unknown  origin  sul)side  without  any  treatment  after  a 
period  similar  to  the  course  of  this  case. 


HEADACHE 


45 


The  rectal  stricture  was  of  the  type  ordinarily  regarded  as  always  or 
usually  syphilitic,  but  on  insufficient  evidence.  There  is  no  good 
histologic  evidence  for  syphilis  in  such  strictures,  whereas  it  is  well 
known  that  gonorrhea  is  prone  to  produce  stricture  in  any  tube.  The 
presence  of  syphilitic  lesions  elsewhere  in  the  body  often  gives  color  to 
the  diagnosis  of  syphilis  in  a  rectal  stricture,  but  in  this  case  there  were 
no  such  lesions. 

The  study  of  the  previous  history  is  of  prime  importance  in  the  diag- 
nosis of  such  cases.  It  revealed  in  this  case  that  the  woman  had  been 
sterile,  but  had  had  no  miscarriages  and  no  lesions  suggesting  syphiUs, 
so  far  as  she  knows. 

If  the  case  is  syphilitic,  it  is  probably  due  to  an  intracranial  lesion  of 
the  type  simulating  brain  tumor.     (See  Case  i,  p.  39.) 

The  prognosis  is  for  immediate  recovery,  but  probable  recurrence,  if 
the  diagnosis  of  syphilis  is  correct,  though  the  recurrence  may  invohe 
any  other  organ  (liver,  aorta,  bones,  subcutaneous  tissues). 

Antisyphilitic  treatment  should  be  continued  at  inter\als  for  life. 
The  interval  depends  on  the  character,  circumstances,  and  {)hysical 
condition  of  the  patient. 

Outcome.-— The  potassium  iodid  was  increased  after  the  first  week 
to  15  grains  and  then  to  30  three  times  a  day.  The  headaches  had 
rapidly  diminished  in  severity  and  frequency.  Slight  signs  of  iodism 
had  in  the  mean  time  appeared.  By  the  eighth  of  June  she  was  feeling 
well  and  ready  to  go  home.  Three  months  later  there  had  been  no 
recurrence. 

Diagnosis.^Sy])hilis  ? 

Case  4 

A  married  cloakmaker,  forty  years  old,  was  seen  June  21,  1894. 
Eight  years  previously  she  had  begun  to  ha\e  womb  trouble,  charac- 
terized by  bearing-down  j)ain  in  the  uj)pcr  abdomen  and  Ijack.  l-'iw 
years  ago  she  had  an  accident  to  her  head,  and  17  stitches  had  to  be 
taken.  Since  then  she  has  liad  unilateral  ''sick  headaches"'  about 
four  times  a  year,  lasting  usually  one  day.  She  b.as  l)et.n  pret'iianl  >i.\ 
times,  and  has  three  times  produced  an  abortion. 

F<nir  weeks  ago  she  began  to  lia\'e  pain  in  the  back  of  lier  neck,  soiiu-- 
times  darting,  sometimes  constant,  worse  in  the  day-tinu',  not  ]iri.-\i'iiting 
sleep.  With  the  pain  there  seemed  to  bt-  a  swelling,  wlu'ch  iiiiprrssrd 
her  as  being  both  inside  the  throat  and  in  thr  najtr.  Shr  had  110  dilli- 
cultv  in  swallowing,  though  hvv  throat  was  somewhat  >orr  at  the  sann- 
time.     Three  weeks  ago  this  pain  e.xtendeil  to  the-  whole  head,  alleiiing 


46  DIFFERENTIAL  DIAGNOSIS 

especially  the  temporal  regions,  which  feel  swollen  and  tender.  She 
has  had  no  other  symptoms. 

Physical  examination  showed  the  patient  sallow  and  covered  with 
a  reddish,  papular  eruption,  with  a  shot-like  feel  under  the  skin.  It  is 
most  marked  upon  the  face  and  trunk.  \^isceral  examination  is  other- 
wise negative,  as  is  the  blood.  The  urine  is  alkaline,  high  in  color,  1023 
in  gravity,  with  the  slightest  possible  trace  of  albumin.  The  sediment 
shows  large  squamous  epithelial  cells  in  clumps,  also  polynuclear  cells, 
triple  phosphate  crystals,  and  some  octahedral  crystals  which  resist  the 
action  of  acetic  acid.     The  fundus  oculi  is  normal. 

Discussion. — Three  types  of  headache  are  immediately  suggested 
as  we  read  the  story  of  this  patient: 

1.  Due  to  trauma. 

2.  Due  to  migraine. 

3.  Due  to  syphilis. 

Traumatic  headaches,  following  violent  cerebral  concussion,  as  in 
foot-ball  or  coasting,  are  apt  to  follow  an  initial  period  of  coma,  and 
usually  persist  steadily  for  wrecks  or  months.  Periodic  pain,  such  as  is 
here  described,  is  not  often  associated  with  trauma. 

Migraine  is  apt  to  appear  before  the  thirty-fifth  year,  and  to  occur 
more  frequently  than  in  this  case. 

It  is  important  to  realize  that  unilateral  periodic  headache  accom- 
panied by  nausea  and  vomiting  deserves  the  term  ^'migraine''''  only  when 
all  known  causes  of  headache  can  be  excluded.  The  headaches  asso- 
cialed  with  nephritis  or  cerebral  tumor  are  often  migrainoid  in  type, 
especially  in  the  earlier  stages  of  the  malady.  The  study  of  the  urine 
and  of  the  fundus  oculi  is  thus  often  omitted  because  the  attacks  are  so 
described  by  the  patient  that  "typical  migraine"  is  assumed  and  treated 
from  the  start. 

A  migrainoid  headache  \\hich  later  became  constant,  aroused,  there- 
fore, the  suspicion  of  nephritis  and  of  cerebral  tumor.  Nephritis,  how- 
ever, could  be  excluded  in  this  case  by  the  absence  of  urinary  changes 
and  of  vascular  hypertension.  The  fundus  oculi  was  negative;  there 
were  no  focal  symptoms  (such  as  aphasia,  paralysis,  Jacksonian  or  general 
epilepsy,  paresthesia,  or  astcreognosis),  and  the  absence  of  vertigo, 
vomiting,  and  vascular  hypertension  also  militated  against  the 
diagnosis  of  cerebral  tumor,  whicli,  however,  could  not  be  absolutely 
excluded. 

Syphilis  is  suggested  by  the  rash.  Further  examination  showed  a 
postcervical  adenitis.  The  absence  of  any  knowledge  of  infection  is  of 
no  importance.     Only  ])0sitive  evidence  is  of  value  in  relation  to  syphilis. 


HEADACHE 


47 


and  it  cannot  be  too  positively  stated  that  in  any  person,  young  or  old, 
rich  or  poor,  whatever  his  character  or  circumstances,  syphilis  is  always 
a  possible  diagnosis.  The  opportunities  for  the  non-venereal  acquisition 
of  syphilis  are  very  many. 

In  this  case  the  rash  was  not  typical,  but  might  have  been  an  ordinary 
skin  infection.  Its  generalized  distribution,  the  associated  adenitis,  and 
the  persistent  headache  made  it,  however,  more  suspicious. 

The  absence  of  miscarriages  is  less  significant,  since  the  abortions 
may  have  anticipated  the  course  of  nature.  On  the  whole,  syphilis  seems 
the  most  proljable  diagnosis. 

The  prognosis  and  treatment  of  syphilis  have  been  sketched  on  ]>p. 
43  and  45. 

Outcome. — The  headache  was  relieved  temporarily  by  5  grains  of 
phenacetin  with  ^  grain  of  codcin.  Later,  some  morphin  was  required  on 
one  or  two  occasions.  Alercury  and  iodid  of  potash  were  gi\'en  ])y 
mouth,  in  small  doses,  and  in  a  week  she  was  very  much  better.  In 
two  weeks  the  headache  was  very  slight,  the  rash  nearly  gone,  the  glands 
barely  palpable.  July  12th  she  was  discharged  well,  with  the  ad^•ice 
to  continue  the  iodid  of  potash  in  5-grain  doses  three  times  a  day  for  a 
number  of  months. 

Diagnosis. — Syphilis. 

Case  5 

A  Jewish  shoemaker  of  thirty-seven  was  seen  July  8,  1908.  He  has 
had  some  trouljle  with  his  stomach  since  he  hrst  came  to  this  country, 
fne  years  ago.  Five  days  ago  he  l^egan  to  ha\'e  "pain  o\er  his  heart," 
followed  by  shortness  of  breath  and  fainting.  This  attack  lasted  only 
a  few  hours,  but  since  that  time  he  hii*  had  severe  headache,  loss  of  appe- 
tite, and  gastric  distress  without  vomiting.  His  bowels  ha\e  become 
constii)ated,  and  his  sleep  is  disturbed  by  bad  dreams. 

On  examination  a  few  fine  transient  rales  were  found  at  the  base 
of  each  lung.  Respiration  at  the  left  base  and  axilla  was  somewhat 
louder  than  on  the  right.  There  was  slight  epigastric  tcndrrness.  and 
tlie  edge  of  the  spleen  was  easily  felt  i^.  inches  below  the  costal  margin. 
'i'hcre  was  anterior  and  internal  l)owing  of  the  right  tibia,  witii  prcnii- 
nence,  but  no  roughening.  The  temperature  at  entrance  was  100°  l.; 
])ulse,  75;  leukocytes  were  4800;  the  Widal  reaction  negati\e.  Illood- 
culture  was  negative;  urine  normal. 

Discussion. — What  are  the  causes  of  i)rominence  or  enlargeireii:  oi 
the  tiljia-:-' 

Sit/nilicance  of  the  rales  in  this  case? 


48  DIFFERENTIAL   DIAGNOSIS 

The  pulmonary  signs  are  not  characteristic  of  tuberculosis  nor  of 
any  other  disease  of  the  lung. 

The  prominence  and  bowing  of  one  tibia  might  be  due  to  old 
rickets,  to  osteitis  deformans  (Paget's  disease),  or  to  syphilitic  changes, 
but  the  latter  are  usually  accompanied  by  roughness,  unevenness,  and 
cutaneous  changes,  while  Paget's  disease  should  atTect  the  femora  and 
the  clavicles  more  extensively  than  the  tibiae.  Rickets  seems  the  more 
likely  explanation. 

An  acute  headache  (five  days'  duration)  with  fever  suggested, 
naturally  enough,  an  infectious  disease.  The  acute  infectious  diseases 
most  often  causing  headache  in  a  temperate  climate  are  the  milder 
respiratory  infections  ("common  colds"),  tonsillitis,  sepsis,  and  typhoid 
— malaria  less  often. 

The  negative  blood  examination,  the  normal  temperature,  and  the 
paucity  of  visceral  lesions  rule  out  these  infections. 

There  are  many  items  pointing  to  a  psychic  origin  for  this  headache. 
It  began  immediately  after  an  attack  of  thoracic  pain,  which  was  evi- 
dently believed  by  the  patient  to  be  due  to  heart  disease — that  terrifying 
affliction.  The  subsequent  bad  dreams  and  gastro-intestinal  disturb- 
ances are  very  common  results  of  a  scare  about  one's  heart,  especially 
in  high-strung  people  like  the  Jews. 

The  therapeutic  test  also  bears  on  the  diagnosis  here.  As  soon  as 
the  patient  was  assured  (after  a  searching  and  thorough  examination) 
that  his  vital  organs  were  sound,  his  headache  and  other  trouble  began 
to  improve.  The  application  of  suggestion  (in  the  form  of  menthol) 
completed  the  cure.  It  is,  of  course,  impossible  to  exclude  some  obscure 
infectious  or  toxic  disease,  but  the  weight  of  evidence  is  against  it. 

Outcome. — ^A  diagnosis  of  typhoid  had  pre\iously  been  made,  but 
the  next  morning  the  temperature  was  normal  and  the  man  complained 
of  nothing  but  headache.  Tliis  continued  for  several  days,  but  was 
relieved  by  a  25  per  cent,  alcoholic  solution  of  menthol  applied  to  the 
painful  part.     Reassurance  played  a  considerable  part  in  his  recovery. 

Diagnosis. — Headache  of  })sychic  origin. 

This  is  a  fit  piace  to  consider  tlie  so-called  "neurasthenic,"  "essen- 
tial," or  "constitutional"  headaches.  There  are  some  persons  so  al)- 
normally  sensitive  to  sensory  stimuli  that  the  weight  of  the  l)ody  gi\cs 
j)ain,  even  when  they  are  seated  on  soft  chairs;  the  ]>ressure  of  tlie  clothing, 
the  ordinary  changes  in  atmospheric  temperature,  hurt  them  as  a  decay- 
ing tooth  is  hurt  by  simple  pressure,  heat  or  cold.  In  sucli  persons  the 
circulatorv  or  neural  processes  in  the  head  may  be  sufficient  to  cross  the 
pain  threshold  and  to  present  themselves  as  pain.     Not  all  such  persons 


HEADACHE  49 

have  any  of  the  mental  or  physical  characteristics  of  the  neurasthenic, 
and  it  seems  to  me  to  darken  counsel  if  we  class  such  headaches  as 
"neurasthenic"  merely  because  we  discover  no  organic  basis  for  them. 

In  another  group  of  persons  the  headache  is  clearly  dependent  upon 
psychic  states,  which  can  be  used  both  to  produce  and  to  allay  the  pain. 
The  suffering  is  forgotten  when  the  person  is  active  and  interested, 
returning  when  the  sufferer's  attention  relapses  upon  himself. 

In  a  third  group  there  are  no  general  hyperesthesia  and  no  variation 
of  the  pain  with  psychic  states.  I  have  followed  several  such  cases 
through  the  period  of  adolescence  and  up  to  their  disappearance  with 
the  end  of  this  state. 

Others  occur  in  later  life,  and  may  be  steady  or  vaguely  periodic. 
Of  this  large  group  we  know  practically  nothing,  and  this  should,  I 
think,  be  plainly  indicated  in  our  terms.  I  believe  then  that  we  should 
distinguish  within  the  so-callcxi  '' neurasthenic"  group: 

(a)  Headaches  due  to  constitutional  or  chronic  hyperesthesia. 

(b)  Headaches  due  to  psychic  causes. 

(f)   Headaches  whose  cause  is  absolutely  unknown. 

As  an  example  of  the  type  last  mentioned,  I  recently  studied  the  case 
of  a  hearty,  vigorous  Italian  laborer  who  began  to  suffer  from  constant 
headache  in  July,  1908.  In  August  I  saw  him  in  consultation,  but 
could  discover  no  cause  for  his  steady  suffering,  which  now  disabled 
him  from  work.  I  sent  him  to  the  jMassachusetts  General  Hospital, 
where  the  most  careful  study  of  his  internal  viscera,  body  fluids,  eyes, 
cars,  nose,  throat,  and  bony  sinuses  revealed  absolutely  nothing.  Just 
as  we  reached  the  end  of  this  fruitless  search  the  headache — after  nine 
weeks'  duration — suddenly  ceased  altogether  without  treatment,  though 
quinin,  mercury,  and  potassium  iodid  had  been  proved  ineffectual  by 
thorough  trial  ])revious  to  his  entering  the  hospital.  Up  to  the  present 
time  (Septeml:)er,  1910)  there  has  \)ccn  no  recurrence  of  pain. 

Case  6 

A  housewife  of  forty-seven  entered  the  hospital  Dcccml)er  23,  igo;. 
Since  tlie  beginning  of  her  menstruation  at  the  ele\cntli  year  she  liad 
noticed  a  fullness  in  tlie  front  of  her  throat,  which  became  more  jironii- 
nent  at  the  time  of  her  first  ])regnancy  in  her  twenty-sixth  year,  it 
became  smaller  after  (leli\'ery,  l)ut  increased  with  tlio  ni'xt  and  \\  itli  i  ach 
of  the  succeeding  eiglit  ])regnancies.  Eacli  tiinc  the  swelling  imrri'.M'd 
more  during  the  ])regnancv  than  it  diminished  after  (leli\er\".  so  tliat  the 
total  effect  has  been  an  increase  of  tlie  tumor.  It  ha^  ne\er  causeel  any 
discomfort  or  inconxenience. 


50  DIFFERENTIAL  DIAGNOSIS 

For  the  past  two  years  she  has  had  "  sick  headaches,"  beginning  earl) 
in  the  morning  or  long  after  eating,  lasting  twenty-four  hours,  coming 
about  once  in  two  weeks,  until  lately,  when  they  have  begun  to  come 
twice  a  week  and  have  been  accompanied  by  nervousness.  She  feels 
hot  most  of  the  time,  and  prefers  cold  weather.  For  six  months  she  has 
noticed  a  weakness  of  her  hands.  Two  weeks  ago  she  had  the  "grip," 
and  has  since  then  noticed  considerable  shortness  of  breath,  amounting 
of  late  to  orthopnea.  She  has  lost  30  pounds  in  the  last  two  years. 
The  bowels  have  been  slightly  loose;  the  appetite  excellent. 

Physical  examination  showed  emaciation,  cyanosis,  a  slight  exoph- 
thalmos (not  previously  noticed  by  the  patient) ,  a  fine  tremor  of  the  hands, 
and  marked  asymmetric  enlargement  of  the  thyroid,  its  greatest  circum- 
ference being  16 1  inches.  The  heart's  impulse  was  in  the  sixth  inter- 
space, I  inch  outside  the  nipple-line,  4  inches  to  the  left  of  mid- 
sternum.  The  action  was  rapid,  ranging  between  100  and  120,  accom- 
panied by  some  irregularity.  The  first  sound  was  very  sharp  at  the 
apex,  and  was  preceded  by  a  presystolic  roll.  The  pulmonic  second 
sound  was  much  greater  than  the  aortic  second  sound.  Systolic  blood- 
pressure,  175  mm.  Hg.  Shadows  and  movements  of  the  intestinal 
coils  were  visible  over  the  abdomen.  There  was  considerable  tender- 
ness in  the  epigastrium  and  about  the  navel.  The  edge  of  the  liver  was 
felt  3  inches  below  the  costal  margin.  There  was  no  ascites,  but  both 
legs  showed  soft  edema  throughout.  The  leukocytes  were  15,400. 
The  blood  was  otherwise  normal.  The  urine  was  pale,  loio  to  1012  in 
specific  gravity,  with  a  trace  of  albumin.  There  were  many  leukocytes; 
no  casts.  The  twenty-four-hour  amount  ranged  betv^'een  15  and  30 
(Ounces. 

Discussion. — i.  What  was  the  nature  of  the  thyroid  tumor? 

2.  What  caused  the  headache? 

3.  Can  any  reason  be  given  for  her  preferring  cold  weather? 

4.  How  are  the  characteristics  of  the  urine  explained? 

5.  Is  there  more  than  one  possible  explanation  of  the  presystolic 
roll  heard  in  this  case? 

6.  Under  what  conditions  are  intestinal  movements  visiljle  through 
the  abdommal  wall? 

7.  What  diseases  produce  loss  of  weight  des})itc  good  appetite  and 
digestion? 

The  discussion  of  these  questions  will  involve  a  statement  of  the  diag- 
nosis, prognosis,  and  treatment. 

Regarding  the  thyroid  tumor,  it  is  clear  that  its  duration  (thirty-six 
years)  excludes  malignant  disease.     We  have  left  the  so-called  "simple 


HEADACHE  5 1 

goiter"  and  "exophthalmic  goiter."  The  case  illustrates  well  the 
transition  from  the  first  to  the  second  condition;  also  the  relation  of  the 
thyroid  to  pregnancy.  From  her  eleventh  to  her  forty-fifth  year  the 
patient  had  no  symptoms  from  her  goiter.  It  was  increasingly  unsightly, 
nothing  more.  After  the  forty-fifth  year  came  the  familiar  sym.ptoms 
of  hyperthyroidism — loss  of  weight  despite  good  appetite,  a  sense  of 
increased  bodily  heat  corresponding  with  the  abnormally  rapid  metabol- 
ism; finally  tachycardia,  tremor,  and  exophthalmos. 

The  only  important  diseases  causing  loss  of  weight  despite  good 
appetite  are  diabetes  (either  form),  Graves's  disease,  and  some  cases 
of  arteriosclerosis.  In  one  of  my  cases  of  Graves's  disease  loss  of 
weight  was  the  symptom  which  brought  the  patient  to  me.  He  wanted 
to  know  why  he  was  losing  weight  despite  an  excellent  appetite.  He 
mentioned  no  other  complaints. 

In  the  present  case  the  emaciation  explains  the  visibility  of  intes- 
tinal peristalsis,  for  emaciation  is  all  that  is  necessary  to  produce  this 
S}mptom.  In  patients  not  emaciated  such  a  sign  usually  means  in- 
testinal obstruction. 

The  condition  of  the  urine  in  this  case  can  hardly  be  explained 
(as  one  might  at  first  think)  as  a  result  of  renal  stasis  due  to  a  dilated 
heart,  for  the  low  specific  gra\ity  and  pale  color  are  the  opposite  of  what 
we  expect  in  renal  stasis.  When  taken  in  connection  with  the  abnor- 
mally high  blood-pressure,  these  features  of  the  urine  suggest  nephritis. 
Such  vascular  hypertension  is  unusual  in" Graves's  disease.  The  head- 
aches are  also  much  more  comprehensible  if  we  suppose  that  the  patient 
had  both  nephritis  and  Graves's.  I  have  already  referred  to  the  fre- 
quency of  so-called  "sick  headache"  in  nephritis,  as  well  as  in  i)rain 
tumor  and  syphilis.    In  simple  hyperthyroidism  headache  is  not  common. 

The  cardiac  signs  suggest,  first  of  all,  a  mitral  stenosis  with  dilata- 
tion of  the  heart,  but  another  possibility  is  to  be  remembered,  namely, 
that  the  dilatation  itself  may  be  the  cause  of  the  murmur.  It  has  been 
repeatedly  noted  of  late  that  not  only  in  connection  with  aortic  regurs^i- 
tation  (the  so-called  Flint's  murmur),  l)ut  in  any  form  of  cardiac  h}])or- 
trophy  and  dilatation  affecting  tb.e  left  Aentricle,  a  presystolic  roll  may 
be  heard  at  the  apex.  Thus  in  adhesive  jxTicarditis  and  in  .^imi'lc 
nephritic  hypertrophy  we  often  hear  such  murmurs.  11. ere  is  no  v.;;y 
of  deciding  in  this  case  whether  or  not  mitral  stenosis  is  ] -resent,  but  it  is  a 
good  rule,  often  l)orne  out  1)y  j)ostmortcm  experience,  to  assmne  as  te.v 
lesions  as  can  be  made  to  explain  the  facts.  On  this  ]>rineij>Ie.  ib.e  (hai;- 
nosis  of  this  case  should  be  (ira\'es's  disease;  chronic  nepliriti-  with 
resulting  cardiac  hyjiertroph)-  and  dilatation. 


52  DIFFERENTIAL   DIAGNOSIS 

The  prognosis  is  for  a  few  months  of  life  at  best.  In  treatment 
rest  is  the  essential.  Morphin,  followed  by  bleeding,  purgation,  and 
diuretics,  may  give  some  relief.     Digitalis  is  not  likely  to  be  effectual. 

Outcome. — The  pulse-rate  steadily  declined  during  her  first  week 
in  the  hospital,  and  the  swelling  became  less;  but  on  January  ist  the 
patient  became  noisy  and  mentally  confused,  the  respiration  slow  and 
deep,  the  breath  having  an  ammoniacal  odor.  There  were  frequent 
attacks  of  severe  dyspnea.  In  the  next  thirty-six  hours  she  was,  for 
the  most  part,  semiconscious,  but  never  unconscious,  and  was  com- 
fortable except  during  the  attacks  of  dyspnea.  Pilocarpin  produced  no 
sweating,  and  attempts  to  give  a  hot-air  bath  were  unsuccessful.  It  was 
impossible  to  purge,  as  she  refused  to  swallow  anything.  Her  heart 
continued  strong  and  not  rapid. 

She  died  on  the  third  of  January. 

Autopsy  showed  chronic  glomerulonephritis  with  hypertrophy  and 
dilatation  of  the  heart  and  general  dropsy;  simple  adenoma  of  the 
•thyroid;  obsolete  tuberculosis  of  the  spleen. 

One  of  the  interesting  points  in  this  case  is  the  existence  of  nephritis 
without  albuminuria  during  the  period  under  observation.  The  blood- 
pressure  gave  more  correct  indication  for  diagnosis,  as  is  often  the  case. 

Diagnosis.— Uremic  headache;  chronic  glomerulonephritis;  hyper- 
thyroidism. 

•     Case  7 

A  young  woman  of  twenty-fi\-e,  a  student,  entered  the  hospital 
November  7,  1907.  One  of  her  aunts  died  of  consumption.  She  was 
treated  by  Dr.  R.  W.  Lovett  for  three  years  for  some  spinal  trouble, 
beginning  with  her  fifteenth  year.  When  she  was  eighteen  her  menstrua- 
tion stopped  and  her  spleen  becam.e  enlarged.  She  was  then  treated  for 
some  time  by  Dr.  Franz  Pfaff.  Two  years  ago  menstruation  again 
ceased  during  the  winter.  The  intervals  between  her  periods  are  still 
five  or  six  weeks  long,  and  she  always  has  headache  during  the  cata- 
menia.  She  has  been  overworked  for  the  past  three  years,  and  has 
been  nervous,  but  has  had  no  actual  breakdown  and  no  hysteric  symp- 
toms; she  has  been  especially  tired  most  of  the  time  since  the  first  of 
October.     She  takes  two  cups  of  tea  and  one  of  coffee  a  day. 

Eight  days  ago  she  found  it  \'ery  hard  to  concentrate  her  mind  upon 
her  v/ork.  The  next  day  she  had  severe  headache,  and  that  night  was 
sleepless.  Six  days  ago  the  headache  became  still  worse,  and  she 
coughed  up  a  little  blood  and  ])hlegm.  E\er  since  then  she  has  coughed 
a  little,  l)ut  without  sputa.     Fi\e  days  ago  she  had  photophobia  and  felt 


HEADACHE 


53 


tender  lumps  upon  the  back  of  her  head.  That  evening  she  had  chill, 
followed  by  sweating.  Three  days  ago  she  had  another  chill,  and  her 
teeth  and  her  left  ear  ached.  This  time  she  began  taking  aspirin  in 
5-grain  doses  for  the  relief  of  her  headache,  and  found  it  \ery  effectual. 
The  last  two  days  her  headache  has  been  less  severe,  but  it  is  still  present 
in  the  back  of  her  head.  She  has  been  slightly  constipated  and  has  felt 
somewhat  weak. 

Temperature,  101.3°  F.;  pulse,  83;  respiration,  18. 

Physical  examination  was  negative,  save  for  a  short,  sharp,  whistling 
systolic  murmur  in  the  pulmonary  area,  transmitted  only  along  the  left 


Fig.  3.-^Chart  of  case  7. 

side  of  the  sternum.  The  abdomen  was  held  sliglitly  rigid  throughout, 
but  was  tym])anitic  and  free  from  tenderness.     The  spleen  was  not  feh. 

Discussion. — Certain  features  in  this  case  suggest  tliat  tlie  lirad- 
ache  mav  l)e  due  to  tuberculors  meningitis.  The  history  of  consunu)- 
tic^n  in  the  familv  and  rf  a  ];rrl(^rgecl  treatment  addressed  to  the  sj-iiu', 
together  with  the  cessation  (>f  ni(  nstrr.ation  at  !ht  eiglUrcntli  vi-ar,  are 
all  factors  \\liicli  make  us  tliink  of  tuberculosis.  The  ])hoto]'holiia,  t(n>, 
is  a  common  meningeal  symptom. 

Against  meningitis,  ho\ve\'er,  is  tlie  absence  of  an)'  tulxTcnlous  ti hus 
now  disco\'('rable  on  jih\'sical  exanunation.  the  absi-n.re  ot  ;iry  !e>;i 'Us 
referable  to  the  cranial  nerxi'S.  and  the  recent  sul)si(lence  of  the  iieadache 
without  an\'  oncoming  coma. 


54 


DIFFERENTIAL   DIAGNOSIS 


Could  this  be  a  neurasthenic  headache,  so  called?  She  is  at  the  age 
when  such  things  are  commonest,  and  there  is  a  history  of  nervousness 
and  overwork.  But  the  continued  fever  seems  to  me  to  make  this  im- 
possible. I  do  not  think  there  is  any  good  evidence  that  a  fever  such 
as  is  shown  in  the  accompanying  chart  ever  results  from  neurasthenia, 
hysteria,  or  any  psychoneurosis. 

Malaria  is  suggested  by  the  chills  and  the  headache,  but  is  excluded 
by  the  absence  of  parasites  in  the  blood.  The  lumps  complained  of  in 
the  occipital  region  were  not  discoverable  on  physical  examination. 
Had  they  turned  out  to  be  glandular,  syphilis  might  have  been  suspected. 

With  the  exclusion  of  the  above  possibilities  we  have  to  consider 
what  diseases  are  the  most  frequent  in  patients  who  have  fever  with  a 
negative  physical  examination  and  a  low  leukocyte  count.  The  answer 
must,  I  think,  be  as  follows :  If  the  fever  is  a  short  one,  it  is  generally 
labeled  "grip"  under  these  conditions,  though  I  prefer  to  call  it  an  un- 
known infection.  If  the  fever  persists  for  two  weeks  or  more  without 
the  development  of  physical  signs,  typhoid  usually  turns  out  to  be  present, 
as  was  the  case  here. 

Outcome. — On  the  right  side  of  the  abdomen  there  developed  later 
two  red  macules  which  decolorized  on  pressure.  The  course  of  the 
temperature  is  seen  in  the  accompanying  chart.  The  Widal  reaction 
was  positive  at  entrance.  Blood  otherwise  negative.  The  course  of 
her  illness  was  uneventful,  and  she  was  discharged  well  on  the  seventeenth 
of  December. 

It  is  worth  emphasizing  the  fact  that  constipation,  cough,  and  chills 
are  common  symptoms  at  the  onset  of  typhoid,  also  that  the  headache 
is  usually  earlier  and  more  prominent  than  in  other  infections.  (For 
the  treatment  of  this  case  see  Appendix,  p.  743.) 

Diagnosis.— Typhoid. 

Case  8 

A  Russian  clerk,  eighteen  years  of  age,  entered  the  hospital  February 
27,  1908.  The  only  history  which  could  be  obtained  from  liim  was 
that  two  days  ago  he  fell  dov/nstairs  and  since  then  he  has  had  a  good 
deal  of  headache. 

Physical  examination  showed  that  he  was  drowsy,  his  right  pupil 
slightly  larger  than  his  left,  Ijoth  reacting  normally.  His  throat  was  red 
and  slightly  swollen.  There  was  considerable  rigidity  of  his  neck,  but 
no  actual  retraction.  Rotation  and  backward  flexion  were  normal, 
but  the  head  could  not  be  bent  forward.  Visceral  examination  ^vas 
entirely  negative,  with  the  exception  of  Kcrnig's  sign,  which  was  present 


HEADACHE 


55 


on  both  sides.  The  temperature  was  100.3°  ^-5  ^he  pulse,  60;  respira- 
tion, 25.  Fundus  ocuh  normal.  Blood  and  urine  normal.  Blood- 
pressure,  145.  During  the  night  he  became  unconscious,  and  the  next 
morning  had  marked  retraction  of  the  head,  unequal  and  unresy)onsive 
pupils,  a  strabismus,  absence  of  superficial  reflexes,  Babinski's  reaction 
on  the  right,  and  a  rectal  temperature  of  102.8°  F. 

Discussion. — Concussion  of  the  brain  and  meningitis  were  the  diag- 
noses at  lirst  suggested  in  this  case.  Any  headache  following  a  fall  on 
the  head  is  rightly  suspected  as  being  due  to  concussion,  but  there  are 
certain  symptoms  in  this  case  not  thus  to  be  explained,  i.  e.,  the 
inequality  of  the  pupils,  the  rigidity  of  the  neck,  and  the  presence  of 
Kernig's  sign. 

These  three  signs,  together  with  the  presence  of  fever  and  slow  pulse, 
the  rapidly  developing  coma,  strabismus,  and  Babinski's  reaction,  all 
point  to  meningitis,  which  was  the  diagnosis  made  at  the  outset. 
Acting  upon  this  a  lumbar  puncture  was  done,  and  35  c.c.  of  bloody, 
turbid  fluid  were  remo\'ed.  The  examination  of  this  fluid,  however, 
showed  nothing  but  macerated  red  corpuscles,  no  micro-organisms 
either  in  cover-glass  or  culture.  This  speaks  strongly  against  epidemic 
meningitis,  while  the  great  rapidity  of  onset  and  the  absence  of  any 
lymphocytosis  in  the  spinal  fluid  make  tuberculous  meningitis  unlikely. 
The  presence  of  blood  in  the  spinal  fluid  suggests  cerebral  hem.orrhage 
or  fracture  of  the  base  of  the  skull. 

Normal  urine  and  normal  blood-pressure  rule  out  uremia,  and  nor- 
mal blood  excludes  malaria.  Brain  tumor  may  manifest  itself  suddenly 
after  a  long  latent  period  by  symptoms  like  those  in  this  case,  but  the 
absence  of  paralysis,  of  changes  in  the  fundus  oculi,  and  the  presence  of 
the  rigid  neck  and  the  bloody  spinal  fluid  militate  against  this  diag- 
nosis. No  al)Solute  decision  was  arrived  at  before  death,  which  oc- 
curred on  the  first  of  !March. 

Outcome. — Auto])sy,  March  ist,  sliov/cd  fracture  of  the  base  of  the 
skull,  multiple  contusions  erf  the  cerebellum  and  frontal  lobes,  with 
hemorrhage. 

Diagnosis. — Fracture  of  the  base  of  tlic  skull. 

Case  9 

A  domestic  of  twenty-three  was  seen  March  14,  1908.  She  was 
perfectly  well  until  noon  of  the  day  before,  when  she  was  sci/rd  wwh 
sharp,  cutting  pain  in  the  forehead  and  a  slight  .^ore  throat,  witli  tt\rr. 
She  went  to  bed  and  slfpt  wril,  but.a\\()ke  wilh  [hv  sanic  hcachiclic.  and 
vomited  when  she  trot  out  of  bed.     'Vhv  lieadachc  has  conlinued  >hue. 


56  DIFFERENTIAL   DIAGNOSIS 

When  seen  at  the  hospital  the  patient's  temperature  was  102.5°  F.; 
her  pulse,  125,  the  skin  hot  and  dry.  The  pupils  were  equal,  regular, 
and  reacted  normally;  the  fundus  negative;  the  throat  slightly  reddened 
and  swollen;  face  t^ushed.  The  viscera,  negative.  Leukocytes,  9000. 
Blood  and  urine  were  otherwise  normal.  Blood-pressure,  125.  During 
the  first  thirty-six  hours  of  her  stay  in  the  hospital  she  suffered  a  good 
deal  with  headache,  relieved  more  or  less  by  phenacetin  and  an  ice-bag 
in  the  frontal  region. 

Discussion. — I  have  known  tuberculous  meningitis  to  manifest 
itself  first  by  intense  pain  at  the  root  of  the  nose,  as  in  this  case.  All 
the  ordinary  symptoms  of  that  disease,  howe\'er,  except  headache  and 
fever,  are  absent  in  this  case.  Typhoid,  malaria,  and  most  other  infec- 
tions are  ruled  out  by  the  negative  physical  examination  and  the  short 
course  of  the  disease,  which  was  practically  gone  in  four  days.  On  the 
third  day  careful  questioning  showed  that  the  pain  was  limited  to  the 
region  of  the  frontal  sinuses.  On  the  eighteenth  she  was  able  to  go  back 
to  work. 

In  ^'iew  of  these  facts  an  infection  of  the  frontal  sinus  seems  the  most 
likely  cause  of  her  headache.  In  some  cases  of  this  disease  the  head- 
ache appears  in  a  characteristic  \vay  at  the  same  hour  each  morning, 
perhaps  owing  to  the  accumulation  of  secretions  during  the  night. 
Sometimes  the  diagnosis  is  assisted  by  the  sudden  appearance  of  a  nasal 
discharge  coincident  with  the  cessation  of  pain;  in  other  cases  the  close 
limitation  of  the  pain  to  the  region  of  the  frontal  sinuses  is  our  best  clew 
to  diagnosis. 

Outcome. — On  the  eighteenth  of  ]\Iarch  she  went  back  to  work. 

Diagnosis. — Sinusitis. 

Case  10 

A  cook  of  twenty-three  entered  the  hospital  April  9,  1908.  Her 
family  history  and  past  history  were  excellent.  Two  months  ago  she 
stopped  work  for  a  fortnight  because  of  fatigue  and  persistent  headache. 
Ten  days  ago  the  headache  returned  and  has  persisted  since.  It  is 
se\ere  in  the  frontal  and  occipital  regions.  Four  days  ago  she  began 
to  vomit,  and  since  then  has  vomited  about  six  times  every  twenty-four 
hours.  E\-en  water  is  rejected.  There  has  been  no  abdominal  ]:>ain, 
but  persistent  nausea.  She  has  had  no  cough  and  no  other  sym]jtoms. 
The  course  of  the  temperature  is  seen  in  the  chart  on  page  57. 
The  white  cells  were  4400  at  entrance,  4900  on  April  20th;  the  Widal 
reaction  al\^■ays  negati\-e;  the  blood  otherwise  ncgati\-e.  Tlie  urine 
ranged  between  20  and  30  ounces  in  twenty-four  hours,  with  a  specific 


HEADACHE 


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gravity  between  1026  and  1036;  a  trace  of  albumin;  a  few  hyaline  and 
fine  granular  casts.  The  pupils  were  equal  and  reacted  to  light  and 
distance;  the  fundus  oculi,  normal;  the  chest  and  abdomen  negative, 
save  for  slight  tenderness  and  rigidity  in  the  epigastrium.  During  the 
first  week  she  seemed  rather  hysteric  at  times,  complained  continually 
of  headache,  and  was  hungry,  but  no  diagnosis  could  be  made. 

Discussion. — Typhoid  is  suggested  by  the  course  of  the  temjjcra- 
ture,  the  subnormal  leukocyte  count,  and  the  headache.  Indeed,  there 
is  nothing  in  the  case,  as  here  stated,  positively  to  exclude  typhoid. 
Against  it,  however,  are  the  long  duration  of  the  headache,  which  is 
usually  gone  after  the  first  ten  days  in  typhoid.  The  persistent  nausea 
is  also  very  unusual  in  typhoid.  Per- 
ha])s  the  strangest  symj^tom,  however, 
is  the  excellent  appetite,  which  is  al- 
most unknown  in  a  patient  seriously 
sick  with  typhoid. 

The  question  of  hysteria  must  be 
considered.  All  the  symptoms  in  the 
case  are  consistent  with  this  diagnosis, 
with  one  exception — the  continued 
fever.  There  is,  in  my  o])inion,  no 
such  thing  as  a  hysteric  fever  of  this 
type.  An  elevation  of  less  than  one 
degree  over  a  considerable  period  or  a 
sharp  sudden,  sh()rt-li\"cd  rise  occurs  in 
hysteria,  but  not  a  persistent  fe\er  of 
this  type. 

The  two  diseases  seriously  to  Ijc 
considered  are  cerebral  syphilis  and 
tuberculous  meningitis.     As   a   matter 

of  fact,  the  diagnosis  of  syphilis  was  made  in  this  case  by  a  skilled 
neurologist.  I'he  entire  alxscncet^f  any  history  and  of  any  visible  k-sions 
of  this  disease  is  not  in  itself  at  all  conclusive  against  it,  ncitlier  is  the 
age  of  the  jjaticnt.  although  tlu"  great  irajorit}"  of  ca^L■^  oi  cvwln'vA 
syphilis  occur  in  older  persons.  More  important  cxidcncc  against 
syj)hilis  is  the  subnormal  leukocyte  count,  which  is  distinctl}'  niw  \n 
sy])hilitic  cases. 

I'lpidemic   meiiingitis  comes  on  more  suddcnlv,   almost  always  ]'ro 
duces  a  Icukocvtosis,  and  usualh'  runs  a  siiortcr  coursi'.      Nr\  i.  rt!u-k\— . 
it  cannot  be  cxclucU-fl  without  an  examination  of  tlie  si>inil  fk^rid. 

Outcome. — April    22d    lumbar    puncture  was  done,  and    ic  c.c.  of 


I'i:;.  4.  —  Chart  of  case  lo. 


58  DIFFERENTIAL   DIAGNOSIS 

clear  pale  fluid  was  obtained,  the  sediment  showing  72  per  cent,  of 
lymphocytes,  28  per  cent,  of  epithelial  cells.  In  the  Thoma-Zeiss  coun- 
ter, this  fluid  showed  42  lymphocytes  per  c.mm.  On  the  twenty-third 
the  patient  seemed  to  be  restless,  the  left  pupil  slightly  larger  than  the 
right.  During  the  forenoon  the  left  hand  became  flexed.  At  noon,  the 
left  leg  and  the  left  side  of  the  face  became  paralyzed,  and  the  reflexes 
absent.  Syphilis,  producing  softening  from  thrombosis  in  the  region 
of  the  right  internal  capsule,  was  suspected.  The  patient  soon  after 
became  semicomatose.  The  head  was  drawn  sharply  to  the  right.  At 
times  the  patient  would  recognize  and  talk  with  her  relatives,  and  is  even 
able  to  move  the  left  arm  and  leg. 

On  the  twenty-fourth  knee-jerk  of  the  right  leg  disappeared,  and  a 
pin  could  be  passed  through  the  skin  of  either  leg  without  pain. 

On  the  twenty-fifth  there  was  left  lateral  conjugate  deviation  with 
lateral  nystagmus,  more  constant  in  the  right  eye.  Respiration  became 
labored.  Edema  appeared  in  the  hands,  and  the  patient  died  at  noon 
on  the  twenty-fifth. 

Autopsy  showed  miliary  tuberculosis  of  the  lungs  and  spleen;  tuber- 
culous meningitis;  tubercular  ulcers  of  the  ileum;  tuberculosis  of  the 
retroperitoneal  glands. 

It  should  be  distinctly  stated  that  cases  of  proved  tuberculous  menin- 
gitis have  recovered.  Probably  this  outcome  takes  place  in  less  than  i 
per  cent,  of  the  cases,  but  it  is  important  to  know  that  it  is  possible. 

Diagnosis. — Miliary  tuberculosis. 

Case  11 

A  house-painter  of  forty-two  entered  the  hospital  December  4,  1907. 
He  is  in  the  habit  of  taking  three  drinks  of  whisky  a  day,  but  has  had 
no  previous  illness.  A  year  and  a  half  ago  he  began  to  have  headaches, 
vertigo,  cramps,  and  vomiting;  was  sick  for  three  or  four  days.  He 
was  treated  in  the  Somerville  Hospital  for  five  weeks,  but  did  not  im- 
prove much,  and  has  been  unable  to  work  since.  He  is  now  troubled 
much  with  occipital  headache,  worse  in  the  morning  and  after  he  has 
been  drinking.  He  now  rarely  vomits.  Last  night  he  had  a  nosebleed. 
He  has  had  no  abdominal  pain  of  late.  He  has  had  occasional  night- 
sweats,  but  none  for  two  weeks.     Headache  is  his  chief  complaint. 

Physical  examination  of  the  chest  is  negative  except  for  a  short 
systolic  murmur  at  the  apex  of  the  heart  and  accentuation  of  the  aortic 
second  sound.  The  pulse  tension  seemed  to  be  high.  The  blood-pres- 
sure was  160  mm.  Hg.  On  the  right  side  of  the  abdomen,  at  the  level 
of  the  navel,   a  smooth,   rounded,   slightlv  tender  m.ass  is  felt.     The 


HEADACHE 


59 


patient  subsequently  said  that  he  had  had  blood  in  his  stools  for  fifteen 
or  sixteen  weeks,  averaging  a  gill  a  day.  An  expert  proctoscopic  ex- 
amination showed  no  sufficient  cause  for  this  blood.  On  examination 
in  a  warm  bath  the  tymor  previously  described  was  much  easier  to  feel. 
It  appeared  to  be  about  the  size  of  a  grape-fruit,  and  connected  with 
the  kidney.  The  urine  was  about  30  ounces  in  twenty-four  hours, 
milky,  1013  in  specific  gravity,  the  sediment  containing  a  large  amount  of 
pus,  and  an  occasional  granular  cast.  The  hemoglobin  was  70  per 
cent. 

Profuse  bleeding  from  the  rectum  continued,  and  vomiting  of  large 
amounts  of  green  material  with  a  little  fresh  blood  happened  several 
times.  The  right  lung  ^^•as  full  of  coarse  moist  and  dry  rales.  X-ray 
showed  a  shadow,  probably  of  stone  in  the  right  kidney.  The  profuse 
intestinal  hemorrhage  suggested  malignant  disease,  but  no  other  evi- 
dence of  it  could  be  found.  The  amount  of  urine  passed  became 
smaller  and  smaller.  On  the  seventeenth  of  December  the  sputum 
became  bloody  and  the  patient  continued  to  vomit  blood  and  to  pass  it 
by  rectum.  Numerous  purpuric  spots  appeared  on  the  skin.  He 
sweated  profusely  in  the  hot-air  baths  and  seemed  better  after  them. 

Discussion. — Although  the  patient  is  somewhat  alcoholic,  there 
certainly  is  not  enough  evidence  to  make  us  believe  that  whisky  is  the 
cause  of  his  sufferings. 

Lead-poisoning  is  naturally  suggested  by  the  patient's  occupation, 
by  the  history  of  abdominal  cramps,  and  headaches.  If  lead-poisoning 
were  present,  it  might  also  account  for  the  renal  symptoms  and  for  the 
rather  high  blood-pressure.  As  a  matter  of  fact,  the  patient  was  treated 
for  five  weeks  for  lead-poisoning,  and  the  fact  that  he  did  not  improve 
during  that  time  is,  in  itself,  against  the  diagnosis.  More  important, 
however,  is  the  tumor  above  described,  which  cannot  possibly  be  ex- 
plained l)y  lead.  The  presence  of  this  tumor,  togctlier  with  the  pus  in 
the  urine  cind  the  results  of  .v-ray  examination,  ])oint  strongly  to  stone 
or  tuberculosis  of  the  kidney.  The  headaches,  pains,  and  sweats  are 
quite  explicable  if  there  is  sup])uration  of  tu]:)ercuIous  or  calculous 
origin  in  the  renal  pelvis. 

We  have  still  to  explain  in  some  way  the  mysterious  hemorrhages 
from  the  rectum,  stomach,  and  rcs[)iratory  tract.  The  accentuation  of 
the  aortic  second  sounrl,  the  ])loo(l-pressure,  the  low  specific  gravity  of 
the  urine,  and  its  constantly  diminishing  amount  suggest  a  c(^nconutant 
nephritis. 

Outcome. — Operation  was  considered,  but  postponed,  owing  to  the 
man's  poor  condition.     During  the  last  two  days  of  life  he  passed  practi- 


6o 


DIFFERENTIAL   DIAGNOSIS 


cally  no  urine.  He  was  irritable  and  unreasonable,  his  mind  wandering. 
He  died  on  the  twenty-second  of  December. 

At  autopsy  the  right  kidney  was  found  to  contain  a  very  large  stone 
and  several  smaller  ones.  Three-quarters  of  the  .organ  was  converted 
into  a  bag  of  pus,  and  the  remaining  portion  showed  as  cystic  degenera- 
tion.    The  left  kidney  showed  the  lesions  of  chronic  glomerulonephritis. 

Diagnosis. — Stone  in  the  kidney  with  abscess  and  nephritis. 

Case  12 

An  electrician  of  thirty- three  entered  the  hospital  September  lo,  1907. 
He  was  perfectly  well  until  two  weeks  ago,  when  he  began  to  ha\-e 


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severe,  shooting  pain  in  the  forehead,  spreading  to  the  rest  of  the  head. 
His  face  ^vas  puffy  and  red  every  forenoon  and  his  hands  became  swollen. 
Yesterday  he  became  very  dizzy  and  could  hardly  see  to  walk,  but  did  not 
fall.     He  lost  three  pounds  in  two  weeks  and  is  thirsty  and  nervous. 

The  patient  was  semicomatose  and  answered  no  questions.  He 
moved  restlessly  upon  the  bed  with  his  eyes  shut  and  his  hand  to  his 
head.  He  was  not  asleep  or  drunk,  and  there  was  no  evidence  that  he  had 
been  drugged. 

On  examination,  the  face  was  distinctly  puffy.  The  muscles  a1)out  the 
eyes  tvv-itched  in^"oluntarily  from  time  to  time.  Fundus  oculi  negati\e. 
The  incisor  teeth  were  worn  do\\n — the  patient  says  because  he  grinds 


HEADACHE  6 1 

them  at  night.  The  spleen  was  not  palpable.  Physical  examination 
was  otherwise  negative.  Blood-pressure,  loo  mm.  Hg.  Temperature, 
102.6°  F.  White  cells,  3400.  Urine  negative.  The  blood  showed 
no  malarial  organisms.  The  symptoms  seemed  to  point  strongly  toward 
uremia  at  the  time  of  entrance,  but  the  urine  was  absolutely  negative. 

At  entrance  the  patient  was  put  into  a  hot  bath,  but  collapsed  twenty 
minutes  later,  his  blood-pressure  being  very  low. 

Discussion. — Nephritis  is  suggested  by  the  drowsy  condition,  the 
edema  of  the  face  and  hands,  and  the  headache.  The  negative  urine 
does  not  necessarily  exclude  chronic  nephritis,  but  the  low  blood-i)ressure 
and  the  normal  size  of  the  heart  are  strongly  against  this  diagnosis. 

Brain  tumor  is  suggested  by  the  headache,  the  vertigo,  and  the 
drowsiness.  Against  it  are  the  negative  fundus  examination,  the  low 
blood-pressure,  the  absence  of  focal  symptoms. 

Migraine  may  produce  symptoms  similar  to  those  in  this  case,  but 
one  almost  never  sees  a  patient  of  thirty-three  in  his  first  attack  of 
migraine,  and  this  patient  had  had  no  previous  attacks  like  this. 

There  is  no  e\idence  of  reflex  causes.  In  fact,  the  diagnosis  was  not 
suspected  until  the  fall  of  temperature  to  normal  next  morning,  and  its 
subsequent  rise  on  the  succeeding  day  suggested  malaria. 

Outcome. — On  the  fourteenth  he  had  a  chill.  The  blood  showed 
a  number  of  fully  grown  malarial  parasites.  Under  quinin  the  patient 
was  well  within  a  few  days. 

Diagnosis.— Malaria. 

Case  13 

A  Russian  housewife  of  fifty-eight  entered  the  hospital  November  30, 
1906.  She  entered  the  hospital  first  in  April,  1906,  suffering  from 
"interstitial  myocarditis"  with  paroxysmal  tachycardia.  She  was  next 
seen  on  the  thirtieth  of  Novem])er;  her  physician  states  that  since  leaving 
the  hosj)ital  she  has  had  attacks  of  tachycardia  every  few  weeks,  the 
attack  usually  lasting  two  days  and  often  accompanied  l)y  headaclie. 
Between  attacks  she  felt  well;  her  appetite  was  good,  lier  bowels  regular, 
there  was  no  loss  of  strength. 

Nine  days  ago  she  began  to  liavc  constant  lieadache,  jirecordia.l  dis- 
tress, insomnia,  and  anorexia.  There  is  now  no  cough  ami  no  (i}>]inea, 
but  she  feels  weak  and  tired. 

Physical  examination  showed  sliulit  j)allor  and  marked  ]>ulsiti()n 
in  tlie  neck.  The  left  border  of  carcHac  (hdncss  was  six  inclies  t<.)  the 
left  of  the  midsternuni  in  the  fifth  space,  the  rii^dit  border  (mc  inch  to  the 


62 


DIFFERENTIAL  DIAGNOSIS 


right  of  midsternum;  sounds  rapid,  but  regular;  the  first  apex  sound 
sharp;  the  second,  barely  audible;  a  rhythm  like  that  of  the  fetal  heart, 
the  rate  something  over  190.  All  the  heart-beats  were  transmitted  to 
the  wrist,  though  the  tension  was  low. 

Physical  examination  was  otherwise  entirely  negative.  During  the 
first  part  of  her  stay  in  the  hospital  the  tachycardia  showed  only  slight 
remissions,  sometimes  for  a  minute,  sometimes  for  several  hours.  The 
rate  did  not  seem  to  be  affected  by  sleep,  talking,  or  food.  Digitalis 
had  no  effect.  Tincture  of  aconite  had  no  effect.  Except  for  weak- 
ness and  some  mental  anxiety,  the  patient  seemed  well. 

Discussion. — Although  the  headache  was  much  complained  of  in 
this  case,  it  was  at  once  thrown  into  the  background  by  the  general 


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■or^-M-ra  «    ^    «j-45|-6      ^    a    d_   'i_U4tv_k3    «    a 

Pig.  6. — Chan  of  case  13. 


physical  examination,  which  made  tachycardia  prominent.  Our  chief 
problem  is  to  interpret  the  tachycardia  existing  in  this  case,  more  espe- 
cially as  regards  prognosis,  which  is  always  the  essential  point  in  tachy- 
cardia. 

Cases  of  paroxysmal  tachycardia  may  Ije  di\'idcd  into  three  groups; 

{a)  Those  having  an  obvious  exciting  cause. 

(6)   Those  occurring  in  the  course  of  a  chronic  cardiac  disease. 

{c)  Those  of  whose  origin  we  ha^'e  no  idea. 

The  first  and  the  last  of  these  groups  carry  a  good  prognosis.  For 
practical  purposes  this  is  the  most  important  point.     I  v.as  once  sum- 


HEADACHE  63 

moned  in  hot  haste  to  the  bedside  of  a  woman  of  forty,  where  I  found 
the  family  assembled  awaiting  her  death.  The  attending  physician 
thought  she  had  but  a  few  hours  to  live.  Her  pulse  was  210,  her  heart 
action  absolutely  regular  and  of  the  fetal  type,  her  heart  not  enlarged, 
her  breathing  slow  and  easy  in  a  recumbent  position.  The  tachycardia 
had  come  on  six  hours  previously,  during  a  family  quarrel,  the  patient 
being  partly  drunk. 

Vigorous  reassurances  were  given  to  the  family  in  the  patient's 
hearing,  but  without  addressing  her.  Within  an  hour  the  tachy- 
cardia ceased. 

I  have  seen  a  similar  attack  in  a  high-strung  young  girl  who  was  in 
the  dentist's  chair  during  menstruation.  The  dentist  was  excessively 
alarmed,  as  the  pulse  was  over  200  and  barely  perceptible,  but  the 
patient  was  as  well  as  usual  next  day. 

Attacks  may  follow  a  gastric  upset  or  come  after  a  surgical  operation. 

Tachycardia  of  this  type  occurring  in  patients  who  have  definite 
signs  or  history  of  cardiac  insufRciency,  whether  from  valvular  or  myo- 
cardial lesions,  are  more  serious,  but  I  have  never  known  a  patient  to  die 
during  or  soon  after  such  an  attack.  The  prognosis  is  that  of  the  under- 
lying lesion,  and  is  not  appreciably  modified  by  the  occurrence  of  tachy- 
cardia. 

Treatment. — Some  cases  are  immediately  relieved  if  the  patient  is 
placed  head  downward  for  a  few  seconds;  others  ha^"e  been  known  to 
recover  immediately  after  by  drinking  ice-water  after  emptying  the 
stomach  or  after  moderate  exercise.     Drugs  have  no  obvious  effect. 

Outcome. — On  the  twelfth  of  December  the  tachycardia  ceased 
during  the  night,  and  on  the  sixteenth  she  had  two  days  without  any. 
rVom  this  ])()int  on  the  attacks  grew  shorter  and  occurred  at  longer  inter- 
vals. There  was  no  evidence  that  they  were  influenced  in  any  way 
by  any  drug  or  other  treatment  given  her,  and  she  left  the  liospital  much 
relieved,  on  the  third  of  January,  though  the  myocardium  still  showed 
evidence  of  weakness. 

Diagnosis. — Paroxysmal  tachycardia  complicating  a  chronic  myo- 
cardial insufficiency. 

Case  14 

A  scho()M)()v  eight  years  old  cntcTcd  the  hospital  ]\Iay  16,  IQ07. 
Since  earlv  cliildhoo;!  he  and  his  l)rotlH'r  and  his  sister  havo  liad 
vomiting  S])ells  about  once  a  montli.  In  such  a  si)ell  he  goes  to  l)rd 
fc'xcrish,  xoniits  in  the  night,  is  fe\erish  and  slec])y  tlie  next  day;  after 
tliat  he  is  perfrctly  wt'll.  It  is  surmised  that  tliese  eUccts  are  due  to 
eatintr  too  much  candv. 


64 


DIFFERENTIAL  DIAGNOSIS 


Five  days  ago  he  had  headache  and  fever  and  vomited  once.  The 
headache  and  fever  have  coniimied  since,  and  he  has  been  unable  to  go  to 
school.  He  has  had  a  slight  loose  cough,  but  no  expectoration.  Last 
night  he  slept  poorly  and  complained  of  epigastric  pain.  The  course  of 
the  temperature  is  seen  in  the  accompanying  chart  (Fig.  7). 

Physical  examination  of  the  head,  neck,  and  heart  was  negative. 
The  abdomen  was  slightly  distended,  tympanitic,  firmly  held,  and  very 
tender  throughout.  The  child  breathed  rapidly,  with  short,  groaning 
expiration.  He  was  admitted  to  the  hospital  with  a  diagnosis  of  acute 
appendicitis.  The  right  lung  showed  dulness 
from  the  apex  to  the  fourth  rib  in  front  and 
over  the  entire  back,  associated  with  bronchial 
breathing,  increased  voice,  and  fremitus. 

Discussion. — I  have  known  several  cases 
like  this  operated  upon  for  appendicitis  owing 
to  the  lack  of  a  thorough  physical  examination. 
Especially  in  children  it  is  essential  to  make  a 
thorough  examination  of  the  chest  whenever  the 
presenting  symptom  is  abdominal  pain.  The 
backs  of  the  lungs  are  often  not  thoroughly 
examined,  because  we  shrink,  very  naturally, 
from  having  a  patient  sit  up  or  even  turn  upon 
his  side;  but  in  a  case  of  this  kind  this  is  a  short- 
sighted kindness. 

Outcome. — On  the  twenty-second  the  tem- 
perature reached  normal  and  the  patient  felt 
finely.  On  the  twenty-fifth  the  temperature 
again  rose,  and  the  white  cells,  which  had  been  35,000  at  entrance,  were 
found  to  be  still  at  approximately  the  same  figure,  with  92  per  cent,  of 
polynuclear  neutrophiles. 

When  fever  persists  in  a  case  of  this  kind  and  the  percussion  dulness 
does  not  clear  up,  one  of  three  possibilities  is  generally  entertained: 
One  thinks  of  an  unresolved  pneumonia,  of  a  pleural  thickening,  or  of 
postpneumonic  empyema.  In  nine  cases  out  of  ten  the  latter  turns  out 
to  be  the  true  diagnosis.  Unresolved  pneumonia  is  mostly  a  myth.  In 
the  vast  majority  of  cases  it  spells  empyema.  Pleural  thickening  causes 
no  such  elevation  of  the  leukocyte  count. 

A  needle  introduced  at  the  right  base  drew  pus  containing  poly- 
nuclear leukocytes  and  pneumococci. 

Diagnosis. — Infection  (post-pneumonic  empyema). 


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Fig.  7. — Chart  of  case  14. 


HEADACHE 


65 


Case  15 

A  little  girl  of  fifteen,  a  chocolate  dipper  by  trade,  entered  the  hospi- 
tal December  27,  1900,  complaining  chiefly  of  headache,  which  she  has 
had  for  three  days.  It  has  been  accompanied  by  some  aching  of  the 
feet,  general  fatigue,  and  weakness.  Her  appetite  has  been  good,  but 
her  food  has  been  frequently  vomited.  She  has  had  to  stay  in  bed  for 
the  past  three  days.  The  course  of  her  temperature  is  seen  in  the  accom- 
panying chart  (Fig.  8). 

Physical  examination  showed  good  nutrition,  flushed  face,  heavy 
eyes,  pupils  equal  and  reacting,  tonsils  enlarged  and  red,  a  soft,  sharply 
localized  systolic  murmur  at  the  apex  of  the  heart;  the  spleen  palpable 
on  inspiration.  The  internal  viscera  were  otherwise  negative;  the  first 
phalanx  of  the  right  ring-finger  was  a 
little  red  and  swollen.  On  the  ulnar  side 
there  were  a  patch  of  granulation  tissue 
and  a  large  bleb,  from  which  pus  could  be 
expressed.  From  the  history  and  spleen 
typhoid  seemed  to  be  the  most  probable 
diagnosis. 

The  Widal  reaction  was  absolutely 
negative.  White  cells,  11,000.  There 
was  a  diazo-reaction  in  the  otherwise 
negative  urine.  The  headache  continued 
very  troublesome. 

On  the  night  following  entrance  the 
patient  complained  of  a  little  pain  in  her 
right  knee,  the  inner  side  of  which  was 
found  to  be  very  slightly  swollen  and 
tender,  not  red  or  hot.  The  next  three 
or  four  days  there  was  the  same  com-  ^^^-  ^•— Chart  of  case  15. 

plaint  at  the  same  time  every  night.      The  knee  gradually  became  more 
swollen,  and  there  was  a  suggestion  of  floating  of  the  patella. 

Discussion. — In  the  early  days  of  this  case,  with  headache,  high 
fever,  and  nothing  to  show  for  it,  it  was  probably  impossible  to  make  a 
definite  diagnosis.  The  presence  of  the  heart  murmur  suggests  an  endo- 
carditis, with  or  without  general  sepsis.  Such  infections  are  very  com- 
mon in  girls  of  this  age.  The  white  count  of  11,000  is  somewhat  against 
this;  the  condition  of  the  ring-finger  favors  it. 

Ty]-)hoid  seems  more  probable  in  many  respects.  The  history  and  the 
enlargement  of  the  spleen  especially  favor  that  diagnosis,  and  the  diazo- 
reaction  would  be  generally  considered  confirmatory  e\i(ience,  while  the 


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i.JL^ii^    ^iSiS^H^Siii 

66  DIFFERENTIAL  DIAGNOSIS 

absence  of  the  Widal  reaction  by  no  means  excludes  typhoid.  In  fact, 
the  only  decided  evidence  against  typhoid  during  the  early  days  of  her 
illness  was  the  leukocyte  count. 

The  headache  and  splenic  enlargement  are  quite  consistent  v.ith 
malaria,  but  the  time  of  year  makes  this  unlikely  and  the  blood  examina- 
tion excludes  it. 

With  the  appearance  of  pain  in  and  about  the  right  knee  thirty-six 
hours  after  entrance  a  new  crop  of  possibilities  springs  up.  Rheumatic 
arthritis  or  gonorrheal  arthritis  comes  first  to  mind.  The  fact  that  only 
one  joint  is  involved  is  against  ordinary  "rheumatism,"  and  in  any  type 
of  arthritis  we  should  expect  more  pain  when  the  fever  and  constitutional 
manifestations  are  as  marked  as  in  this  case. 

I  have  recently  seen  a  case  of  trichiniasis  with  symptoms  a  good  deal 
like  those  in  this  case,  and  absolutely  without  eosinophilia  during  the 
first  week  under  observation.  In  this  case  the  diagnosis  was  made  by 
finding  the  trichinella  embryo  in  the  peripheral  blood. 

Osteomyelitis  should  always  be  considered  in  a  case  presenting  the 
symptoms  here  described.  It  is  not  at  all  unusual  to  have  the  fever  and 
constitutional  manifestations  precede,  by  a  considerable  interval,  any 
localization  of  the  process.  We  get  strongly  the  impression  that  the 
infection  is  first  general  and  later  local. 

Occasionally  we  see  a  case  beginning  exactly  like  this  one,  but  going 
on  to  rapid  recovery  without  ever  presenting  symptoms  any  more  definite 
than  those  here  described.  We  have  then  to  be  content  with  surmising 
that  some  low-grade  infection  has  been  overcome. 

Outcome. — On  January  2d  the  temperature  was  still  high,  and  the 
knee  intermittently  painful.  At  times  the  patient  awoke  from  sound 
sleep  complaining  bitterly  of  knife-like  pain  in  her  knee.  The  swelling 
increased  over  the  inner  condyle  of  the  femur,  where  there  was  also  the 
greatest  tenderness.  There  was  no  cording  of  the  veins,  no  glandular 
enlargement  or  tenderness,  no  edema  of  the  leg. 

January  6th:  "The  swelling  of  the  knee  has  been  increasing.  The 
whole  leg  is  now  somewhat  swollen.  At  the  knee  it  measures  i  \  inches 
more  in  circumference  than  the  left.  The  patella  now  floats.  Leuko- 
cyte count  is  now  16,000.  At  entrance  it  was  only  11,000.  The  tem- 
perature is  also  lower,  and  in  the  past  two  days  there  has  been  some  de- 
crease in  the  swelling.  There  was  a  diazo-reaction  in  the  urine  at  the 
time  of  entrance,  and  this  has  persisted  since. 

"January  9th:  Pain  in  and  around  the  knee  has  been  very  severe  in 
the  last  three  days.     The  leukocyte  count  is  now  19,300." 

January  loth:  Incision  over  the  outer  condyle  of  the  femur  liberated 


HEADACHE  67 

two  ounces  of  greenish  staphylococcus  pus.  Three  perforations  were  found 
in  the  periosteum  at  the  lower  end  of  the  femur,  with  pus  all  around  the 
bone.  The  bone  was  opened  and  pus  found  in  the  lower  epiphysis  and 
the  lower  end  of  the  shaft.     Convalescence  normal. 

Diagnosis. — Staphylococcus  infection  (osteomyelitis). 

Case  16 

A  laborer  of  thirty-six  entered  the  hospital  September  25,  1906. 
For  three  years  he  has  complained  of  indefinite  stomach  symptoms. 
For  sixteen  months  these  symptoms  have  been  more  marked,  but  have 
not  amounted  to  actual  pain,  though  they  have  been  severe  enough  to 
prevent  his  working ;  there  has  been  no  vomiting.  During  these  sixteen 
months  he  has  had  fairly  constant  headache,  not  localized,  not  very 
severe,  but  often  accompanied  by  vertigo.  A  year  ago  he  was  so  sick 
that  he  was  in  bed  four  months,  after  which  he  was  much  improved,  and 
has  not  been  in  bed  since. 

His  bowels  move  from  one  to  three  times  a  week,  and  only  with 
purgatives  or  encmata.  He  has  no  appetite  and  has  lost  about  thirty 
pounds.  He  has  had  many  doctors,  many  diagnoses,  and  much  treat- 
ment.    He  denies  alcoholic  excess  and  venereal  disease. 

Physical  examination  shows  slight  irregularity  and  sluggish  reactions 
in  the  pupils;  the  left  is  larger  than  the  right,  and  there  is  right  external 
strabismus.  There  is  a  well-marked  tremor  of  the  tongue  when  pro- 
truded, and  at  times  his  lips  arc  tremulous,  as  are  his  hands.  The  edge 
of  the  liver  is  palpable  on  deep  inspiration.  The  knee-jerks  are  lively, 
Achilles  jerk  normal.  White  cells,  12,000;  urine  normal.  Gastric 
examination  with  the  stomach-tube  showed  the  lower  border  of  the 
organ  reached  two  inches  below  the  umbilicus;  its  functions  and  secre- 
tions appaired  to  be  normal.     Visceral  examination  otherwise  negative. 

Under  daily  lavage  and  Zander  treatment  with  vi]:)rations  he  showed 
some  improvement.  He  took  a  good  deal  of  exercise  and  gradually 
acquired  a  good  ai)petite. 

Discussion. — The  questions  wliich  we  naturally  ask  ourselves  in 
this  case  are  as  follows: 

1.  Can  this  be  a  "neurasthenic"  headache? 

2.  Can  it  be  due  to  eye-strain? 

3.  Has  it  any  connection — (a)  With  the  gastrectasis  or  (b)  with  the 
pupillary  changes? 

A  "neurasthenic  "  headache — /.  c,  one  of  unknown  cause  and  l)enign 
outcome — is  suggested  by  the  long  course  of  the  symptoms,  by  tlie  ab- 
sence of  fever  and  visceral  lesions,  and  by  the  apparent  ner\(v.:sness 


68  DIFFERENTIAL  DIAGNOSIS 

manifest  in  trembling  of  the  lips  and  hands.  But  against  this  hypothesis 
is,  in  the  first  place,  the  fact  that  he  is  a  day-laborer  and  has,  therefore, 
no  right  to  such  troubles  unless  under  the  influence  of  alcoholism  or  some 
severe  and  obvious  mental  strain.  Furtlier,  this  hypothesis  does  not 
explain  the  irregularity  and  sluggishness  of  the  pupils  nor  the  tremor  of 
the  tongue. 

Eye-strain  causes  chronic  headache,  and  the  strabismus  here  present 
might  well  be  a  favoring  cause.  How  long  that  strabismus  has  existed  the 
patient  has  no  idea,  but  it  is  certainly  a  very  old  affair  as  compared  with 
the  headache.  Again,  it  is  inherently  unlikely  that  a  day-laborer  should 
begin  to  suffer  from  eye-strain  at  thirty-three.  The  point  could  only  be 
definitely  settled  by  a  more  accurate  examination  of  his  eyes. 

Dementia  paralytica  is  distinctly  suggested  by  the  association  of 
pupillary  defects  with  the  tremor  of  the  tongue  and  lips  and  the  chronic 
headache.  The  absence  of  a  syphilitic  history  does  not  exclude  the 
existence  of  that  disease.  We  might  expect  more  change  in  the  reflexes 
and  more  obvious  mental  symptoms,  but  these  are  by  no  means  neces- 
sary. The  diagnosis  could  be  made  much  more  certain  in  case  the 
spinal  fluid  obtained  by  lumbar  puncture  contained  an  excess  of  cells 
with  a  lymphocytosis. 

Outcome. — By  the  eleventh  of  October  his  stomach  ceased  to  trouble 
him,  but  he  showed  a  marked  lack  of  initiative;  he  was  perfectly  content 
to  sit  and  gaze  absent-mindedly  at  nothing  in  particular.  He  expressed 
himself  as  greatly  improved,  and  had  gained  a  couple  of  pounds.  It 
was  subsequently  ascertained  that  he  had  been  in  an  insane  asylum  in 
November  and  December,  1905.  There  they  obtained  a  history  of  con- 
vulsive attacks,  said  to  be  brought  on  by  eating,  and  characterized  by 
twitching  of  both  arms,  with  numbness  of  hands,  occurring  daily  for 
about  a  week  and  lasting  something  less  than  an  hour.  During  these 
attacks  he  was  sometimes  unconscious,  and  after  coming  out  of  them, 
failed  to  recognize  people  for  a  considerable  time. 

While  at  the  asylum  his  eyes  showed  typical  Argyll -Robertson 
pupils.  The  knee-jerks  were  exaggerated,  and  there  was  a  Babinski 
reaction  on  the  left,  with  marked  incoordination  of  the  upper  extremities 
and  in  the  gait.  Examination  of  the  eyes  was  entirely  negative.  Men- 
tally, he  seemed  more  cheerful  than  the  situation  justified. 

Diagnosis. — Dementia  paralytica. 

Case  17 

A  widow  of  seventy-three  was  seen  March  8,  1907.  She  had  a  fall 
at  twenty-one,  was  hurt  inwardly  and  doctored  for  ten  years.     She  had 


HEADACHE  69 

"brain  fever"  at  twenty-four,  and  was  four  months  in  bed.  Ten  years 
ago  she  had  an  attack  similar  to  the  present  one,  but  less  severe.  She 
has  become  very  nervous  in  the  last  few  years.  Six  weeks  ago  she  was 
taken  with  sharp  pain  in  the  eyes,  spreading  later  to  the  top  of  the  head 
and  the  left  side  of  the  face,  sometimes  shooting  along  the  jaws  or  behind 
the  ears.  The  pain  has  been  steady  during  these  weeks — at  times  sharp 
enough  to  make  her  cry  out.  Light  hurts  her  eyes.  Cold  increases 
the  pain,  and  her  jaw  is  so  painful  that  she  cannot  chew. 

Physical  examination  showed  obesity,  but  was  otherwise  negative. 
When  the  patient's  attention  was  turned  from  herself,  she  seemed  to 
be  perfectly  happy.  One  night  she  kept  the  whole  ward  awake  because 
of  an  indefinite  fear  that  something  was  going  to  happen  to  her. 

Discussion. — In  this  case,  as  in  the  l^st  one,  dementia  paralytica 
is  suggested,  but  there  is  really  very  little  to  support  that  supposition. 
The  tremors  and  pupillary  signs  present  in  the  last  case  are  quite  absent 
here. 

Although  the  pain  here  started  in  the  eyes,  there  is  nothing  else  in  the 
case  to  suggest  eye-strain,  and  as  the  suffering  has  not  been  closely  lim- 
ited to  the  region  of  the  frontal  sinuses,  we  have  no  good  reason  to  sup- 
pose any  inflammation  there. 

In  genuine  neuralgia  we  cannot  ease  the  pain  by  diverting  the  pa- 
tient's attention. 

On  the  whole,  the  headache  seems  to  be  one  of  that  large  class  of 
mysteries  from  which  we  divert  our  attention  because  we  are  unable  to 
give  them  a  name  and  because  they  pass  off  fairly  quickly.  Xo  doubt 
in  this  case  the  psychic  condition  was  in  some  way  an  important  cause. 

Outcome. — On  examination  by  an  eminent  alienist  she  showed  no 
proof  of  insanity,  but  was  believed  to  be  a  nervous,  hy{)ochondriac, 
weak-minded  old  lady.  Magnesium  sulphate,  1]  ounces  daily,  seemed 
to  do  her  good.  She  was  easily  controlled  Ijy  reason  and  by  appealing 
to  her  better  nature.  Since  the  first  night  when  she  raised  the  roof  for  a 
time  she  had  no  bursts  of  temper  or  loss  of  self-control.  The  pain 
did  not  seem  to  mean  much,  and  she  was  discharged  on  the  nine- 
teenth. 

Diagnosis. — Headache  of  unknown  origin. 

Case  18 

An  Irish  housewife  of  twenty-three  entered  the  hospital  A])ril  30. 
IQ07.  She  was  confined  eighteen  days  ago,  the  labor  being  accompanied 
bv  a  large  loss  of  blood.  At  the  end  of  a  week  she  coniplaiiud  of  a 
severe  pain  in  the  side  of  her  face;  later  in  the  otlur  side  as  well,  but  was 


70 


DIFFERENTIAL  DIAGNOSIS 


able  to  get  up  and  take  care  of  the  baby.  Last  night  the  doctor  found 
her  in  a  slight  stupor,  which  has  increased  during  to-day.  The  course 
of  the  temperature  is  seen  in  the  accompanying  chart  (Fig.  9). 

The  patient  was  semicomatose,  had  considerable  pigmentation  of 
the  face  and  neck,  normal  pupils,  twitching  right  eye-brow,  pulse  of 
high  tension,  viscera  otherwise  negative;  reflexes  normal;  urine  normal; 
red  cells,  3,832,000;  white  cells,  10,000,  with  76  per  cent,  polynu clears. 
By  May  2d  Kernig's  sign,  photophobia,  and  marked  stiffness  of  the  neck 
had  developed.  The  patient  moaned  continuously,  and  had  headache 
unless  she  was  kept  under  morphin. 


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Fig.  9. — Chart  of  case  i8. 

Discussion. — Any  headache  near  the  time  of  parturition  naturally 
suggests  uremia  or  some  related  autointoxication,  but  in  this  case  nothing 
was  found  in  the  examination  of  the  urine  or  of  the  heart  to  support  these 
ideas. 

Cerebral  hemorrhage  or  embolism  is  not  uncommon  near  parturition, 
but  would  probal^Iy  have  a  more  sudden  onset  and  produce  paralysis 
or  aphasia. 

Cerebral  tumor  should  l)c  considered  and  cannot  be  excluded  with- 
out an  examination  of  the  fundus.  The  al)scnce  of  focal  symptoms 
and  the  presence  of  Kernig's  sign,  photophobia,  and  retracted  head 
militate  against  it. 

Meningitis  is  left  as  the  most  plausible  diagnosis,  though  the  tem- 
perature-chart and  the  leukocyte  count  are  against  it. 


HEADACHE  7 I 

Outcome. — On  lumbar  puncture  a  clear  fluid  spurted  eight  inches 
through  the  cannula ;  immediate  and  great  relief  followed.  The  patient 
ceased  moaning  and  went  to  sleep.  A  sediment  of  the  fluid  thus  ob- 
tained showed  very  rare  leukocytes  or  degenerate  mononuclear  cells 
and  a  few  Gram-decolorizing  bacteria  not  characteristic.  Cultures 
remained  sterile;  urine,  normal.  After  the  lumbar  puncture  the 
pupils,  which  were  previously  inactive,  became  normal,  the  Kemig 
sign  less  marked,  and  the  head,  though  still  stiff,  was  not  retracted.  By 
the  thirteenth  of  May  there  was  marked  improvement.  The  tempera- 
ture, as  seen  by  the  chart  on  p.  70,  was  entirely  normal.  I>ess  mor- 
phin  was  required  to  control  the  headache.  Consciousness  returned 
on  the  ninth  of  May.     May  13th  she  fed  herself. 

May  19th :  Marked  improvement.   Sits  up  daily.   No  stiffness  of  neck. 

May  28th:  Red  cells,  4,380,000;  leukocytes,  4000;  hemoglobin,  65 
per  cent. 

May  29th:  The  patient  anxious  to  go  home  and  is  discharged. 

Just  what  type  of  meningitis  was  present  could  not  be  determined. 
At  the  present  day  an  injection  of  Flexner's  antimeningeal  serum  would 
probably  be  indicated,  despite  the  dubious  results  of  this  lumbar  puncture. 

Diagnosis. — Meningitis, 

Case  19 

A  married  woman  of  thirty-live  entered  the  hospital  December  9, 
1897.  She  had  septicemia  after  the  birth  of  her  baby,  six  years  ago. 
She  has  never  been  quite  as  well  since.  For  three  weeks  she  has  had  a 
little  cold  in  her  head  and  a  little  headache,  gradually  getting  worse, 
until  four  days  ago,  when  she  went  to  bed.  Three  days  ago  she  began 
to  have  severe  "neuralgic"  headache,  localized  just  al)ove  the  left  eye. 
She  has  had  a  hard,  dry  cough,  which  is  now  somewhat  better;  and  for 
three  days  there  has  been  some  pain  in  the  left  chest  on  full  inspiration. 

Physical  examination  showed  the  evidences  of  intense  suffering  from 
headache,  marked  tenderness  at  tlie  exit  of  tlie  left  su])ra-orbitul  ncr\e, 
and  less  marked  tenderness  over  its  distril)uti(m.  There  is  consi(leral)!e 
voluntary  s])asm  of  the  right  rectus  abdominis.  The  tem])erature 
is  Too.5°  F.;  pulse,  90;  respiration,  25;  wliite  cells,  14,000;  urine,  nor- 
mal. Freezing  the  supra-orl)ital  nerve  with  ethyl  chlorid  ga\e  no  nlitf. 
]M()ri)hin  in  ^;-grain  dose  eased  the  pain,  1)ut  soon  after  she  l)c''janH; 
hysteric,  noisy,  a.ppreliensixe,  and  almost  delirious.  Slic  sat  uj)  in  Ik'iI, 
treni])ling,  breathing  rapidlv,  witli  widt-Iy  dilated  pupils,  said  shr  tn.ild 
not  get  her  breath,  and  wanted  something  to  counteract  the  rttcc  t  nt  the 
morphin. 


72  DIFFERENTIAL  DIAGNOSIS 

Discussion. — The  problems  presented  by  this  case  are: 

1.  Is  the  headache  due  to  neuralgia,  to  frontal  sinusitis,  or  to  some 
other  cause? 

2.  What  is  the  significance  of  the  thoracic  pain  and  of  the  abdominal 
spasm? 

3.  What  was  the  nature  of  the  acute  attack  following  the  administra- 
tion of  morphin? 

The  fact  that  no  relief  was  afforded  by  freezing  the  supra-orbital 
nerve  argues  against  neuralgia.  Sinusitis  is  made  more  likely  by  the 
direct  sequence  of  the  symptoms  upon  a  cold  in  the  head.  There  is 
nothing  in  the  history  to  suggest  any  other  diagnosis. 

Regarding  .the  cause  of  the  thoracic  pain  and  the  abdominal  spasm, 
we  must  say,  in  the  light  of  the  outcome,  "ignoramus."  It  should  be 
said  with  emphasis  that  in  almost  every  carefully  studied  case  there  are 
one  or  two  facts  like  these  which  stray  across  the  clinical  field  quite  wild 
and  untamed,  and  never  submit  to  any  rational  explanation.  If  a  case 
does  not  manifest  some  such  S}Tnptom,  but  reels  itself  off  like  a  text- 
book account,  I  always  suspect  that  it  is  carelessly  reported. 

At  the  time  of  the  acute  attack  abo\-e  described  meningitis  was  sus- 
pected on  account  of  the  association  of  the  mental  symptoms  and  head- 
ache, but  there  was  at  no  time  any  fever,  and  the  results  of  treatment 
(see  beloW')  made  it  obvious  that  it  was  one  of  those  semihysteric  attacks 
of  excitement  which  not  infrequently  follow  the  administration  of  mor- 
phin in  idiosyncratic  individuals. 

Outcome. — She  was  reassured  in  regard  to  her  breathing,  and 
given  common  salt  in  water  to  counteract  the  morphin,  after  which  she 
was  quiet  for  the  rest  of  the  night.  The  next  morning  the  pain  had  al- 
most disappeared.  The  temperature  was  normal,  and  on  the  third  day 
she  was  allowed  to  go  home. 

Diagnosis. — Sinusitis. 

Case  20 

A  farmer  of  thirty-five  was  seen  October  8,  1906.  x'\bout  August  ist 
he  began  to  have  eruptions  described  as  resembling  giant  urticaria  in 
various  parts  of  his  body.  He  had  previously  been  treated  for  an  attack 
of  angioneurotic  edema.  In  the  middle  of  August  he  had  smothering 
sensations  in  his  chest,  which  lasted  from  one  to  three  hours.  The 
coagulation  time  of  his  blood  was  then  two  minutes. 

Four  and  a  half  days  ago  he  began  to  have  headache,  which  has 
grown  rapidly  worse.  Two  days  ago  he  had  a  chill  at  3  p.  m.,  and 
yesterday  one  at  7  p.  m.     Fever  has  been  continuous  since  the  onset. 


HEADACHE 


73 


The  bowels  have  moved  but  once  in  three  days.  He  has  lost  much 
money  of  late,  but  says  he  does  not  worry  about  it. 

Physical  examination  showed  palpable  glands  in  the  neck,  axillae, 
and  groins.  Examination  of  the  chest  and  abdomen  was  negative. 
The  blood  showed  no  Widal  reaction. 

Discussion. — The  questions  which  naturally  present  themselves  in 
this  case  are: 

I.  Can  the  headache  and  fever  be  due  to  some  of  the  urticarial  group 
of  lesions,  which,  as  we  know,  are  sometimes  associated  with  fever  and 
sometimes  manifest  themselves  in  the  internal  organs  (respiratory 
and  gastro-intestinal  tracts)?    The  smothering  sensations  complained 


■SE-r  1 «    1   '•  1'  !••   'i  'V  T  a  .7  ,S  "i  xo  J.I 

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Pig.  10.—  Chart  of  case  20. 

of  in  August  may  have  indicated  the  involvement  of  the  respiratory  tract 
by  lesions  of  the  urticarial  group. 

2.  Can  financial  worry,  owing  to  his  money  losses,  account  for  his 
symj)toms? 

3.  "What  is  the  significance  of  the  general  glandular  enlargement?-* 
leukemia?  syphilis? 

In  relation  to  the  first  question  it  must  Ije  said,  first  of  all,  that 
urticarial  or  erythematous  lesions  almost  never  occur  on  mucous  surfaces 
and  serous  membranes  alone.  If  the  fever  and  headache  were  of  this 
tyi)e,  there  ought  to  be  some  external  lesion. 

Neither  worry  nor  any  other  ])sycluc  event  ])roduces  a  fe\er  like 
that  here  shown. 


74  DIFFERENTIAL  DIAGNOSIS 

The  text  states  that  glands  are  palpable  in  the  neck,  axillce,  and 
groins,  but  this  is  far  from  indicating  that  the  glands  are  now  in  a  dis- 
eased condition.  Glands  are  palpable  in  health  in  a  large  majority 
of  adults  in  one  or  more  of  the  above-mentioned  situations.  Neverthe- 
less, the  possibility  of  leukemia  cannot  thus  be  dismissed.  I  recently 
saw  a  leukemic  case  with  signs  much  like  those  here  described,  and 
with  a  total  leukocyte  count  nearly  the  same,  the  differential  count,  how- 
ever, showing  95  per  cent,  of  lymphocytes.  As  a  matter  of  fact,  this 
examination  was  made  in  the  case  here  under  discussion,  but  the  blood 
was  wholly  normal. 

General  glandular  enlargement  certainly  suggests  syphilis,  but  such 
enlargement  was  not  present  in  this  case,  the  glands  being  no  bigger 
than  normal.  There  is  nothing  else  in  the  case  to  suggest  syphilis, 
though  a  fever  of  this  type  is  quite  compatible  with  syphilis. 

The  suggestion  of  malaria  (chills)  was  promptly  negatived  by  the 
blood  examination. 

The  clinical  picture  then  is  that  of  a  Jever  with  nothing  to  show  for 
it.  This  makes  us  suspect  typhoid,  especially  in  October.  The  absence 
of  Widal  reaction  at  this  stage  of  the  fever  is,  of  course,  not  evidence 
against  typhoid.  Still  the  diagnosis  is  not  certain.  Is  there  any  way  of 
making  it  more  certain?     Blood  culture  should  certainly  be  undertaken. 

Outcome. — ^A  blood  culture  showed  a  bacillus  giving  all  the  reactions 
of  the  typhoid  organism.  White  cells,  6000.  The  Widal  reaction  did 
not  appear  until  the  seventeenth.  The  course  of  the  fever  was  unevent- 
ful.    He  was  discharged  well  on  the  eighth  of  November. 

This  case  well  illustrates  the  value  of  blood-cultures,  which  are  most 
likely  to  be  positive  at  the  very  time  when  the  Widal  reaction  oftenest 
fails  us,  viz.,  at  the  begiiming  of  the  disease. 

For  the  treatment  of  this  case  see  Appendix  B. 

Diagnosis. — Typhoid. 

Case  21 

A  sailor  of  twenty-seven  entered  the  hospital  November  26,  igo6. 
He  has  lost  one  sister  of  "  meningitis."  Six  months  ago  he  had  malaria, 
with  chills  every  second  day  for  tliree  weeks.  He  has  not  felt  perfectly 
well  since.  He  denies  \'encreal  disease.  Two  weeks  ago  he  began  to 
have  slight,  throbbing  headache,  with  blurring  of  eyes  and  general 
fatigue.  Three  days  later  he  felt  feverish.  Eight  days  ago  th.e  head- 
ache became  severe  enough  to  confine  him  to  bed,  \\'here  he  has  been 
since.     His  appetite  has  been  poor.     Vomiting  has  been  frequent.     He 


HEADACHE 


75 


has  lost  much  weight  and  strength.     The  course  of  the  fever  is  seen  in 
the  accompanying  chart  (Fig.  ii). 

On  physical  examination  the  right  pupil  was  found  to  be  slightly 
larger  than  the  left;  both  reacted  normally;  heart  and  lungs  normal, 
except  that  respiration  at  the  left  apex  was  rather  harsh,  with  slight 
dulness.  A  rare  sibilant  rale  was  heard  over  this  area.  White  cells, 
8300;  polynuclear  cells,  80  per  cent.;  there  were  no  malarial  parasites. 
Widal  reaction  negative,  November  26th,  29th,  and  December  ist. 
The  urine  was  normal;  fundus  oculi  perfectly  nor- 
mal; sputa  negative;  stools  normal. 

Discussion. — Naturally,  our  first  thought  is  of 
typhoid,  but  after  ten  days  of  fever  the  temperature 
should  be  higher  in  typhoid,  unless,  indeed,  we  are 
dealing  with  one  of  the  rare  abortive  cases  which 
finish  themselves  up  within  ten  days,  so  that  we  are 
here  seeing  only  the  tail  end  of  the  disease.  Against 
this,  however,  militates  very  strongly  the  total 
leukocyte  count  (almost  always  subnormal  at  this 
stage  of  typhoid),  and  especially  the  high  percentage 
of  j)olynuclear  cells,  which  is  practically  unknown 
under  these  conditions. 

The  history  of  a  previous  malaria  makes  that 
disease  worth  a  moment's  consideration,  but  as  this 
individual  has  not  been  out  of  a  temperate  climate 
for  many  months,  it  is  practically  impossible  that  he 
should  have  acquired  an  estivo- autumnal  malaria, 
which  is  the  only  type  com])atible  with  a  fever-curve 
like  that  shown  below.  The  patient's  occupation  brings  syphilis  to 
our  minds  as  a  possibility,  but  there  is  nothing  else  about  the  case  to 
support  this  supposition. 

Brain  tumor  often  produces  a  remarkably  slow  pulse,  such  as  is  seen 
in  til  is  case,  but  there  is  nothing  else  about  the  patient  to  verify  this 
hypothesis.  The  fact  that  the  patient  is  ob\iously  sick  and  yet  has  a 
very  slow  pulse  directs  our  attention  still  furth.er  to  the  ])()ssilHhty  of  a 
brain  lesion.  C\in  he  be  sulTering  from  tubi'rculous  meningitis?  There 
are  no  disturbances  of  tlu;  cranial  ner\es  nor  retraction  of  the  h.ead,  and 
no  Icukocvtosis,  but  the  lung  signs  suggest  a  ])ossil)le  tul)erculosis  there. 
Lumbar  puncture  should  certainly  be  dtme  unless  further  exidenct.-  soon 
appears  to  clear  U])  the  diagnosis. 

Outcome. — On  the  twenty-eighth  slight  stiffness  of  tlic  neck  on 
forward  bending  was  noticed;  otherwise  there  was  no  change. 


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case  21. 


76 


DIFFERENTIAL  DIAGNOSIS 


On  the  twenty-ninth  he  became  slightly  delirious,  and  in  the  evening 
required  restraint  and  refused  to  swallow. 

On  the  first  of  December  he  became  comatose,  and  the  stiffness  of 
his  neck  disappeared.  On  the  third  of  December  he  died.  Autopsy 
showed  general  miliary  tuberculosis  and  tuberculosis  of  the  mesenteric 
and  retroperitoneal  glands. 

Diagnosis. — Miliary  tuberculosis. 

Case  22 

A  bricklayer  of  sixty-four  entered  the  hospital  May  15,  1908.  Three 
uncles  upon  his  father's  side  died  of  consumption;  his  family  history 
is  otherwise  good.  He  takes  from  a  pint  to  a  quart  of  whisky  a  day; 
has  had  gonorrhea  many  times;  had  chancre  fourteen  years  ago,  for  which 
he  was  treated  three  years.  He  was  down  South  at  the  time  the  present 
illness  began,  two  weeks  ago;  he  does  not  seem  to 
know  exactly  how  he  got  there.  He  has  been  in 
bed  for  a  week  and  a  half,  complaining  of  nothing 
but  headache  and  poor  appetite. 

On  examination,  his  pupils  are  equal,  regular, 
and  react  normally.  His  temperature  is  as  seen 
in  the  accompanying  chart.  His  tongue  is  covered 
with  a  thick,  dry  coat.  The  heart-sounds  are  faint. 
A  faint,  systolic  murmur  is  heard  all  over  the  pre- 
cordia,  transmitted  into  the  axilla.  The  aortic 
second  sound  is  slightly  accentuated;  heart  not  en- 
larged; the  arteries  palpable.  In  the  lower  half  of 
the  right  lung,  behind,  slight  dulness,  diminished 
breathing,  many  medium  and  coarse  crackling  rales; 
abdomen  and  reflexes  normal;  white  cells,  13,600; 
urine  normal;  Widal  reaction  negative. 

The  patient  was  sent  in  with   a  diagnosis  of 
typhoid  fever,  but  showed   at  entrance  only  head- 
ache and  bronchitis  in  an  alcoholic  subject. 
May  19th:   The  hospital  record  states  that  he  does  not  need  hospital 
treatment,  and  will  be  sent  home  in  a  day  or  two. 

May  2ist:  On  the  morning  visit  he  seemed  "dopey";  for  the  past 
two  nights  he  has  complained  of  severe  headache.  At  11  p.  m.  May  21st, 
he  was  found  unconscious. 

Discussion. — The  family  history,  the  presence  of  lesions  suggestive 
of  a  pleurisy  at  the  base  of  the  right  lung,  suggest  the  possibility  of  a 
tuberculosis  with  involvement  of  the  meninges.     This  could  only  be 


-Chart  of 
case  22. 


HEADACHE 


77 


partially  excluded  by  lumbar  puncture,  and  must  remain  a  possibility 
in  the  diagnosis  of  this  case. 

Headaches  with  nocturnal  exacerbations  suggest  syphilis,  especially 
in  a  patient  who  has  certainly  had  that  infection  in  previous  years.  It 
is  impossible,  however,  to  go  beyond  suspicion  unless  we  can  get  further 
evidence,  such  as  disturbances  of  the  cranial  nerves,  of  the  reflexes,  a 
positive  Wassermann  reaction,  or  other  syphilitic  lesions. 

The  history  naturally  suggests  alcoholism  ("wet  brain"),  but  in  the 
absence  of  any  sign  of  delirium  tremens  this  seems  unlikely,  since  the 
amount  of  alcohol  consumed  in  the  last  ten  days  has  been  almost  nil. 

Typhoid  and  other  infections  disappeared  from  consideration  when 
the  temperature  fell  to  normal  and  stayed  there. 

Can  the  diagnosis  be  malaria?  The  patient  has  recently  come  from 
a  malarial  country,  where  he  may  have  acquired  a  type  of  the  infection 
not  characterized  by  the  familiar  tertian  or  quotidian  chills  seen  in  tem- 
perate climates.  In  a  case  very  similar  to  this,  occurring  in  a  drummer 
who  had  recently  returned  from  a  southern  trip  complaining  of  fever, 
headache,  and  prostration  without  chills,  I  found  large  numbers  of 
estivo-autumnal  "rings"  in  the  red  cells.  The  present  case,  however, 
showed  no  such  evidences  in  the  blood. 

It  is  much  to  be  regretted  that  we  made  no  measurement  of  blood- 
pressure  in  this  case.  An  elevated  pressure  would  support  the  sup- 
position that  some  brain  lesion  (tumor,  hemorrhage,  softening,  or 
meningitis)  existed.     As  it  was,  no  diagnosis  was  made  during  life. 

Outcome. — In  the  evening  the  pupils  ceased  to  react;  the  left  arm 
and  leg  w£re  cooler  than  the  right;  Babinski  on  both  sides;  abdominal 
reflexes  absent;  no  paralysis  made  out.     He  died  on  the  twenty-second. 

Autopsy  showed  subdural  cerebral  hemorriiage;  hemorrhage  into 
tegmentum  of  epencephalon;  arteriosclerosis;  atheromatous  endocarditis 
of  the  aortic  valve;  fibrous  endocarditis  of  the  mitral  valve;  hyi)ertro])hy 
of  the  heart;  syphilitic  cirrhosis  of  liver;  ])roncho])ncumonia;  acute 
fibrinous  pleuritis;  congenital  cyst  of  kidney;  round  ulcer  of  stomach; 
fibrocalcareous  tuberculosis  of  the  lungs;  chronic  pleuritis;  subca})sular 
hemorrhage  of  kidney. 

Diagnosis. — Cerebral  hemorrhage. 


78 


DIFFERENTIAL  DIAGNOSIS 


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CHAPTER    III 
LUMBAR  PAIN 

Some  years  ago,  when  I  was  doing  a  good  deal  of  work  on  the  blood, 
I  was  asked  to  substitute  as  visiting  physician  to  a  convalescent  home 
intended  primarily  for  tired  domestics  and  shop-girls.  The  matron 
met  me  with  that  patient  and  respectful  expression  which  long  service 
under  many  enthusiastic  young  physicians  produces  in  some  nurses. 
"I  hear,"  she  said,  "that  you  are  specially  interested  in  the  blood. 
Dr.  R.,  the  gynecologist,  who  was  visiting  last  autumn,  found  that  all  the 
patients  were  gynecologic.  When  Dr.  C.  visits  us  in  summer,  he  finds 
them  all  nose  and  throat  cases — that's  his  specialty.  Now  that  you  are 
to  visit  us,  I  suppose  they  will  all  turn  out  to  be  hlood  cases." 

It  must  be  explained  that  there  was  no  election  on  the  patients'  part. 
They  did  not  seek  the  institution  because  they  heard  that  Dr.  X.  (a 
specialist  in  their  particular  trouble)  was  on  duty.  They  were  sent 
there  by  a  variety  of  other  physicians  who  had  no  knowledge  of  the 
interests  of  the  different  attending  specialists. 

Now,  in  a  similar  way,  we  may  explain,  I  think,  the  various  interpre- 
tations of  backache  given  by  different  physicians,  each  according  to  his 
point  of  view.  To  the  gynecologist  backaches  are  usually  gynecologic 
symptoms;  to  the  orthopedist,  they  result  from  sacro-iliac  disease  or 
postural  strain;  to  the  neurologist,  they  represent  one  phase  of  hal)it- 
pain  due  to  a  psychoneurotic  make-up.  There  are  stomach  specialists 
who  explain  backache  as  a  result  of  malnutrition,  gastroptosis,  or  consti- 
pation (loaded  colon). 

So  it  goes!  The  one  thing  which  remains  unchanged  is  the  backache. 
When  we  find  15  or  20  drugs  recommended  for  one  disease,  we  are  in- 
clined to  believe  that  none  of  them  has  mucli  value.  Similarly,  wlicn 
wc  find  many  and  various  ex])lanations  for  one  condition,  it  is  natural 
to  doubt  whether  any  of  them  are  true. 

The  one  thing  clear  about  the  obscure  backaches  called  "functional." 
"postural,"  "uterine,"  "sacro-iliac,"  etc.,  is  relief  by  mecluDiieol  eom- 
prcssion  exerted  al^out  the  pelvis  and  lower  lumbar  region  by  nican<  of 
corsets,  plaster  stra])ping,  Ix'hs,  or  i)laster-of-Paris. 

In  many  cases  a  strong  neurotic  element  can  be  traced — the  ir.ental 
or  nervous  weakness  actinia  on  the  back  through  a  reduction  o[  nniscular 
tone.     Flabby  mind,  fiabby  muscles,  unsu])])orted  joints,  pain.     Doubt- 


8o  DIFFERENTIAL  DIAGNOSIS 

less  any  of  these  factors  (and  probably  various  others)  may  so  "activate" 
the  rest  that  in  various  ways  the  back  may  be  made  to  ache.  I  do  not 
think  that  any  one  knows  much  about  it. 

On  the  gynecologic  side  the  most  careful  study  of  backache  (and 
other  pains)  in  relation  to  pelvic  disease  is  that  reported  by  Dr.  C.  T. 
Dercum,^  of  Philadelphia,  in  which  she  shows  statistically  what  I  have 
long  believed  from  unrecorded  but  fairly  extensive  observations  in  the 
Women's  Medical  Clinic  of  the  Massachusetts  General  Hospital,  viz., 
that  there  is  no  type  of  backache  or  other  "  reflex"  pain  which  can 
reasonably  be  referred  to  pehic  disease.  All  types  of  pain  in  the  back, 
head,  and  extremities  occur  with  equal  frequency  with  and  without 
pelvic  disease.  All  types  of  pelvic  disease  exist  with  and  without  back- 
ache. Even  deep-seated  cancerous  growths  may  be  latent  and  symptom- 
less for  many  months. 

The  tables  on  page  83  from  Dr.  Dercum's  article  show  to  my  satis- 
faction the  mutual  independence  of  backache  and  pelvic  disease. 

Aside  from  this  huge  group  of  backaches  cured  by  mechanical  sup- 
port and  lateral  compression  of  the  pelvis,  but  explained  in  many  ways, 
as  gynecologic,  neurasthenic,  or  functional,  as  sacro-iliac  strain  or  as 
loss  of  balance,^  etc.,  we  have  two  other  aflfections  which  I  have  found 
it  convenient  to  bracket  with  it  under  the  clumsy  title  of  the  orthopedic 
group  of  backaches.     These  diseases  are: 

1.  Lumbago. 

2.  Hypertrophic  spondylitis. 

These  may  be  for  a  time  indistinguishable  from  each  other  and  from 
the  larger  and  vaguer  group  above  referred  to. 

The  '^kidney  group"  of  causes  for  backache  is  a  term  which  I  shall 
use  throughout  this  chapter  to  denote  the  "surgical"  diseases  in  or  near 
the  kidney:  tuberculosis,  stone,  neoplasm,  abscess,  cystic  degeneration. 

The  "pressure  group"  refers  to  diseases  which  involve  a  progressive 
compression  of  the  lumbar  cord  or  its  nerves:  aneurysm,  neoplasm, 
vertebral  tuberculosis. 

Some  of  the  commonest  causes  of  lumbar  pain  will  not  be  discussed 
in  any  detail  here.  Probably  more  persons  experience  such  discomfort 
as  a  result  of — 

(a)  Fatigue  and  simple  weariness  than  from  any  other  single  cause. 
The  patient  usually  finds  this  out  when  the  pain  goes  off  after  a  rest. 

^  The  Nervous  Disf^rders  in  Women  Simulating  Pehic  Disease;  An  Analysis  of  591 
Cases,  Jour.  Amer.  Med.  Assoc.,  March  13,  1909,  p.  848. 

-  Reynolds  and  Lovett,  An  Experimental  Study  of  Certain  Phases  of  Chronic  Back- 
ache. Jour.  Amer.  Med.  Assoc .,  March  26.  iqio,  p.  1033. 


Causes  of  Lumbar  Pain 


1.  FATIGUE  AND   DEFECTIVE    BALANCE    ("FUNCTIONAL  ] 

BACK") 

2.  CHILDBIRTH 

3.  INFECTIOUS  DISEASES 

4.  POSTOPERATIVE 


CASES  TOO  MANY 
AND  TOO  VAQUELY 
ENUMERABLE  FOR 
GRAPHIC  REPRE- 
SENTATION. 


5.  SACRO-ILIAC  DISEASE) 

(NON-INFECTIOUS)     i 

6.  LUMBAGO 

7.  HYPERTROPHIC  | 

ARTHRITIS  t' 

8.  HERPES  ZOSTER  | 

("SHINGLES")      • 

9.  INFECTIOUS    ARTHRITIS^ 

OF  SPINE  i 

10.  ACUTE   SPRAIN    OF   THE) 

BACK  I 

11.  RENAL  STONE 

12.  SPINAL  TUBERCULOSIS 

13.  RENAL  SUPPURATION 

14.  PERINEPHRIC  ABSCESS 

15.  RENAL  TUMOR 

16.  CANCER  OF  THE  SPINE 

17.  RETROPERITONEAL  (^ 

TUMOR  I 


711 

549 
351 

214 

178 

149 

109 
72 
65 
26 
16 
6 


LUMBAR  PAIN  83 

TABLE    I. 

Location  of  Pain  or  Tenderness.                                  Pelvis  Pelvis 

Normal.  Diseased. 

Both  groins  (so-called  ovarian  tenderness) 70  14 

Left  groin  (so-called  ovarian  tenderness) 40  14 

Right  groin  (so-called  ovarian  tenderness) 20  3 

Under  both  breasts  (inframammary  tenderness) 2  o 

Under  left  breast  (inframammary  tenderness) 26  2 

Under  right  breast  (inframammary  tenderness) i  o 

On  either  side  of  the  spine  in  the  cervical  region 3  i 

On  either  side  of  the  s{)ine  in  the  dorsal  region 14  2 

On  cither  side  of  the  spine  in  the  lumbar  region 9  4 

Over  the  sacrum 14  3 

At  the  end  of  the  coccyx 10  2 

Abcjve  the  spines  of  the  scapula; 4  o 

Clavus  hystericus 5  3 

Deep  intrapelvic  pain  (hysteric) 10  o 

Painful  areas  on   mucous  surfaces,   vagina,   vulva,  rectum,   and 

tongue 4  o 

Limt>aihc  (legs,  thighs,  arms,  and  shoulders) 40  3 

Sacral  backache 60  10 

Lumbar  backache 2  7 

Headaches,  vertical 3  o 

Headaches,  diffuse 6  2 

Headaches,  frontal  and  occij)ital 35  3 

Headaches,  occipital 26  5 

Headaches,  frontal 16  3 

Hysteric  vomiting 3  o 

Hysteric  {)ain  in  one  eye  during  menstruation i  o 

Hysteric  globus y  "         o 

Disturbed  sleej) 18  5 

Ins(3mnia 3  o 

Gastro-intestinal  clisturbani csof  nervous  f)rigin,  such  as  constipa- 
tion, flatus,  gastric  distress,  diminished  secretions,  and  ano- 
rexia     96  12 

TABLE    H. 

Backache,  heaflache,  anil  other 
Patmciiocic  Condition.  hysteric  or  neunistheiiic 

symptoms. 

Atisent.  Present. 

Cystii   degeneration  i>f  the  cervi.x 3  o 

Tulio-ovarian  inflammations  and  exudates 53  34 

Fibriiid  gmwlhs,  including  one  weighing  17  pounds 11  4 

(\T\ii  al  and  jierineal  ku  (-rations 3q  21 

1  )vsmetiorrhea 7  23 

.■\nteflexions 24  jS 

Rclro]iositions 44  3'> 

Spl;iii(  hiioptosis  (relaxation  of  uterine  sui)ports) h;  3 

La(  cratioiis  ihat   were  repaired 2  o 

Wtirre  lx>th  ovaries  had  t)een  remo\c(i ()  o 

Where  one  ovar\'  had  been  removed 2  o 

AX'liere  the  a])])eii(lix  had  been  removed \  o 

("areiiioma    (no    nervous   s\iiiptonis    found    in    an\-    cas<'   of    ear- 

c  iiii  >ma  ) ()  o 

Pelxii    organs  normal o  i^^i 


84  DIFFERENTIAL   DIAGNOSIS 

Sometimes,  ho\ve\er,  the  fati-^iie  has  become  cumulative,  and  is  so 
chronic  that  it  has  develo])ed,  as  it  were,  into  a  member  of  the  household. 
Its  source  and  origin  may  have  been  forgotten,  and  come  to  light  only  after 
close  questioning  or  as  a  result  of  a  therapeutic  test,  viz.,  a  thorough  rest. 
In  persons  of  high-strung,  hypersensitive,  and  neurotic  temperament, 
these  simple  fatigue  pains  merge  into  what  may  be  called — 

{b)  The  psychoiwurotic  backaches,  which  ha\"e  certain  character- 
istics worth  noting  here.  Pains  of  this  type  are  often  confined  to  the 
region  of  the  coccyx,  and,  unfortunately,  they  are  apt  to  lead  the  patient 
into  the  hands  of  some  fervid  and  eager  surgeon,  who  speedily  does  an 
operation  on  the  coccyx.  If  the  operation  is  followed  by  prolonged  rest 
with  hypernutrition  and  a  considerable  amount  of  reeducation  given 
consciously  or  unconsciously  by  the  surgeon  or  his  assistant,  the  patient 
may  recover,  but  the  credit  is  falsely  given  to  the  operation,  which  would 
have  been  quite  useless — as,  indeed,  it  often  proves — without  the  nutri- 
tive and  educational  influences  linked  to  it. 

Another  type  of  psychoneurotic  backache  makes  the  patient  ab- 
normally conscious  of  the  whole  length  of  his  vertebral  column,  which  is 
affected,  not  only  by  pain,  but  by  a  variety  of  paresthesiae,  tingling,  sen- 
sations of  heat  or  cold,  sensations  of  pressure  or  crawling.  This  type  of 
trouble  may  arise  without  any  obvious  reason,  but  it  is  also  often  met 
with  following  some  accident,  whence  the  term,  "railway  spine."  In  the 
vast  majority  of  these  cases,  however,  the  accident  has  served  merely 
to  direct  the  patient's  attention  to  a  certain  part  of  the  body,  in  this  case 
the  spine,  and  also  to  perturb  his  moral  consciousness  through  the  ex- 
pectation of  damages  and  court-room  scenes. 

A  third  type  of  psychoneurotic  backache,  to  which  further  reference 
will  be  made  Ijelow,  is  recognizable  by  its  obvious  connection  with 
psychic  and  especially  emotional  states.  A  depressing  emotion  will 
])roduce  it,  a  Joyful  event  will  cure  it;  but  one  must  beware  of  doing  the 
patient  injustice  by  dublnng  the  pain  imaginary  or  unreal,  either  in  this 
or  any  other  type  of  })sychoneurotic  trouble.  What  the  facts  show  is 
that  a  certain  direction  and  morljid  concentration  of  attention  is  fol- 
lowed by  pain,  and  that  a  new  habit  of  life,  physical  and  mental,  leading 
to  a  more  prf)fitable  direction  of  attention,  is  follo\^ed  by  relief.  The 
most  plausi1)le  hyj)othesis,  and  also  the  most  useful  one,  because  the 
most  helijfully  com])rchensible  to  the  patient,  is  that  which  assumes 
the  followin.y;:  Xuml^erless  ])hysiologic  changes  are  occurring  e^■ery 
moment  in  ever}-  part  of  our  anatomy — the  circulation  of  blood,  the 
distention  and  contraction  of  blood-\essels,  the  movements  of  lymph- 
r^urrents,  tlie  \arying  tension  and  pressure  of  muscular  masses,  ligament- 


LUMBAR   PAIN  85 

ous  strands  and  fasciae — all  these  and  presumably  many  otlicr  phenom- 
ena go  on  very  busily  but  quite  unconsciously  when  our  minds  are  normal; 
but  when  attention  gets  caught  and  concentrated  upon  the  spine  or  the 
coccyx  or  the  back  of  the  neck,  and  when  the  patient  has  made  a  mental 
picture  of  the  organ  which  he  supposes  to  be  diseased  ("the  base  of  the 
brain,"  "the  whole  spinal  cord,"  "the  outlet  of  the  stomach,"  "the 
left  ovary"),  then  this  unfortunate  begins  to  be  aware  of  physiologic 
processes  normally  unfelt.  This  \-ery  awareness,  through  the  forma- 
tion of  brain  habits  and  ]:)Ossibly  also  through  vasomotor  influences 
acting  upon  the  [)oints  supposed  to  be  diseased,  reinforces  and  increases 
the  sensations  referred  to  this  ])oint  until  they  linally  attain  the  dignity 
of  pain,  which  ultimately  becomes  a  habit  ("habit  pain"). 

I  shall  not  try  to  exemplify  in  any  detail  this  type  of  pain,  though  it 
is  one  of  the  most  common  in  the  jjractice  of  all  busy  physicians. 

(c)  Lumbar  pain  due  to  parlurilion  is  only  rarely  mistaken  for  any 
other  variety,  and  offers,  as  a  rule,  very  little  diagnostic  difficulty. 
Obviously,  it  is  one  of  the  commonest  of  all  such  causes. 

{(I)  BackacJie  from  infectious  disease  of  any  t}-])e,  from  a  simple 
cold  to  the  severest  se})ticemias  and  pneumonias,  is,  I  su])pose,  the  next 
commonest  variety.  Occasionally  this  type  offers  some  difficulties  in 
diagnosis,  examples  of  which  will  be  considered  later.  In  the  great 
majority  of  cases,  however,  the  jjresence  of  fexer,  headache,  and  widely 
distributed  pain  in  other  parts  of  the  body  enables  us  to  identify  infec- 
tious backache  without  much  difficulty. 

u)  Postoperative  backache  aj)pears  usually  about  twenty-four  hours 
after  the  oj)eration,  and  is  troublesome  for  the  next  two  or  three  days. 
Though  often  associated  with  gaseous  distention  of  the  lower  bowel, 
there  seems  to  me  to  be  no  good  reason  to  believe  that  the  distention 
causes  the  ])ain,  since  similar  distention  is  so  commonly  ])resent  in 
typhoid,  jmeumonia,  and  other  infectious  diseases  without  any  back- 
ache. The  ])ostoperati\e  lumbar  pain  seems  to  be  more  common  after 
prolonged  operations  in  which  the  })atient's  l)ack  rests  upon  a  flat  table, 
so  that  the  normal  spinal  cur\'ature  is  no  longer  maintained  l)y  muscular 
tone,  which  the  anesthetic  relaxes.  Pressure  by  the  surgeon  or  his 
assistant  u])on  the  patient  during  o|)eration  may  contriliute  to  the 
result.  If  this  explanation  be  correct,  the  backache  should  be  ])re\\'nte(l 
by  padding  or  cur\ing  tlie  surface  of  tlu'  table  to  correspond  ^^ith  (lie 
norma.  1  hmibar  cur\e  of  the  spine. 

Tht'  types  of  lumbar  j)ain  next  to  be  discussed  all  differ  from  those 
al)o\e  mentioned  in  two  important  resoects:  those  listed  so  far  ha\e 
been  far  commoner  than  those  still  to  l)e  mentioned,  and  far  les-  deoend- 


86  DIFFERENTIAL  DIAGNOSIS 

ent  upon  direct  physical  examination  for  their  recognition.  It  is  for 
this  latter  reason  that  diagnostic  difficulties  are  far  commoner  in  the 
still  remaining  groups  already  mentioned  on  p.  80. 

(/)  The  Orthopedic  Group. — What  was  almost  universally  called  lum- 
bago ten  years  ago  has  now  been  split  up  into  three  main  subtypes  of 
disease:  spinal  osteo-arthritis,  sacro-iliac  disease  (non-tuberculous), 
and  a  residue  still  known  under  the  name  of  lumbago.  Despite  the 
important  differences  which  have  now  been  demonstrated  and  have 
given  rise  to  this  separation,  these  three  diseases  are  still  loosely  bound 
together  by  the  fact  that  their  treatment  is  very  similar.  It  is,  however, 
altogether  for  reasons  of  convenience  in  the  discussion  of  differential 
diagnosis  that  I  have  linked  them  together  under  the  title  of  the  orthopedic 
group.  They  differ  sharply,  both  in  prognosis  and  treatment,  from  all 
the  types  of  disease  above  referred  to,  as  well  as  from  those  next  to  be 
described. 

(g)  The  pressure  group  of  diseases  causing  lumbar  pain  includes 
vertebral  tuberculosis  (Pott's  disease),  aortic  aneurysm,  and  neoplasm 
in  or  near  the  spinal  column.  I  am  quite  aware  that  this  term  has  no 
other  merit  than  that  of  convenience  for  discussion,  since  in  two  members 
of  the  lumbago  group  pressure  is  also  the  cause  of  the  pain. 

(h)  The  kidney  group  of  causes  for  lumbar  pain  includes  renal  stone, 
tuberculosis,  neoplasms,  hematogenous  infection  of  the  kidney,  and  para- 
nephritic abscess  as  its  chief  members.  Among  the  rarer  causes  for 
lumbar  pain  may  also  be  mentioned  renal  infarct,  hydronephrosis, 
pyonephrosis,  and  cystic  kidney. 

(i)  Lumbar  neuralgia  or  neuritis,  clearly  recognizable  only  in  the 
presence  of  the  vesicular  eruption  (herpes  zoster  or  shingles),  is  a  com- 
parati\'ely  rare  cause  for  lumbar  pain.  Of  about  equal  rarity  as  a  cause 
of  such  pain  is— 

(j)  Cholelithiasis. — -Perhaps  one  case  of  gall-stones  in  a  hundred  shows 
itself  by  pain  starting  in  the  back  and  working  toward  the  gall-bladder 
instead  of  in  the  opposite  direction,  as  is  usual. 

With  lumbar  pain  or  tenderness  due  to  ulcer  or  cancer  of  the  stomach 
or  bowel  I  have  had  no  experience,  though  I  have  asked  and  examined 
for  such  pain  many  times.  Schmidt^  mentions  very  specifically  that  in 
lead-poisoning  sharp  lumlmr  pain  is  occasionally  associated  with  the 
ordinary  abdominal  colic. 

To  investigate  the  cause  of  lumbar  pain  it  is  well  to  ask  the  follow- 
ing questions: 

^  Pain,  Its  Causation  and  Diagnostic  Significance,  by  Rudolph  Schmidt,  translation 
published  by  Lippincott. 


LUMBAR   PAIN  87 

(i)  Is  it  unilateral  (diseases  of  the  renal  group  especially)  or  bilateral? 

(2)  Is  it  of  long  duration?  Chronic  lumbar  pain  points  especially 
to  the  psychoneuroses  and  to  the  pressure  group  of  causes. 

(3)  Is  it  made  much  worse  by  stooping  or  sidewise  bending?  This  is 
the  characteristic  of  the  lumbago  group  and  of  many  psychoneurotic 
cases,  while  diseases  of  the  pressure  group  and  the  kidney  group  are  not 
thus  characterized. 

(4)  Is  the  lumbar  region  sensitive  to  pressure  or  percussion?  Such 
sensitiveness  is  especially  common  in  diseases  of  the  renal  group,  but  if 
localized  over  the  sacro-iliac  joint,  it  often  points  to  disease  there. 

(5)  Does  pain  radiate  along  the  course  of  the  intercostal  nerve? 
This  occurs  especially  in  the  lumbago  group  and  the  pressure  group. 

(6)  Does  the  urine  contain  blood  or  pus? 

EXAMINATION   OF  PATIENTS   WITH   LUMBAR   PAIN 

Incredible  though  it  seems,  there  are  physicians  in  practice  to-day 
who  do  not  hesitate  to  treat  lumbar  pain  without  stripping  the  patient 
so  that  the  naked  back  can  be  examined.  I  have  known  a  case  of 
herpes  zoster  to  be  treated  for  "  rheumatism  "  (salicylates,  alkalis, 
vegetable  diet,  etc.)  simply  because  the  vesicular  eruption  was  unknown 
to  the  patient  and  had  never  been  looked  for  by  the  physician. 

Osier  mentions  a  case  of  aneurysm  of  the  descending  thoracic  aorta, 
which  presented  as  a  pulsating  tumor  near  the  angle  of  the  left  scapula, 
quite  undiagnosed  through  many  weeks  of  treatment  for  lumbago  and 
neuralgia.  The  attending  pliysician  had  never  examined  the  ex])()sed 
back,  presumably  because  the  ])atient,  being  a  male,  wore  clothes  which 
opened  in  front  and  did  not  offer  to  remove  them. 

Once  we  have  formed  the  habit  of  examining  the  naked  back,  we 
should  note  especially: 

(a)  Is  the  spine  rigid  locally  or  throughout  ?  (Allowance  must  be 
made  for  the  moderate  rigidity  of  normal  old  age.) 

(b)  Is  there  any  tenderness  o\er  the  sj)inous  ])roccss(.'s? 

(c)  Is  there  any  dulncss  on  percussion  of  the  bases  of  (he  lun^s? 
(Renal  abscess  or  neoplasm  may  ]iush  up  the  dia])hragni  ami  encroach 
upon  the  thoracic  space.) 

((!)  Does  the  patient  stand  or  walk  with  a  list  to  one  side? 
(c)  Has  he  any  fc\'er  ? 

Case  23 

A  Swedish  linsmitli,  twenty  years  of  age,  of  excellent  faniilv  history, 
past  history,  and  habits,  entered  the  hospital  on  the  iweiily-lifth  of  June, 


88  DIFFERENTIAL   DIAGNOSIS 

1908.  On  June  7th,  while  sitting  in  a  chair  upon  his  piazza,  he  had  a 
sudden  attack  of  sharp  pain  in  the  right  lower  back.  This  pain  con- 
tinued severe  for  the  next  six  da}'S,  and  on  the  day  after  its  onset  he  began 
to  be  short  of  breath  on  slight  exertion.  A  dr\'  cough  began  at  the  same 
time,  and  has  persisted  since.  His  appetite  has  been  poor,  but  he  has 
not  been  in  bed.     He  has  had  no  constipation  or  other  symptoms. 

When  first  seen,  his  temperature,  pulse,  and  respiration  were  normal. 
His  heart's  apex  was  i'*  inches  to  the  left  of  the  nipple-line  in  the  fifth 
space,  the  right  border  of  cardiac  dulness  two  inches  to  the  left  of  the 
midsternum  line  in  the  fourth  space.  The  heart-sounds  were  of  good 
quality,  and  there  were  no  murmurs.  The  upper  part  of  the  right  chest 
was  slightly  dull  as  low  as  the  third  rib.  Below  this  there  was  tympany 
extending  two  inches  to  the  left  of  the  midsternal  line,  below  the  costal 
margin,  and  to  the  middle  of  the  right  axilla.  Tactile  fremitus  was 
diminished  o\-er  this  area,  and  breath-sounds  distant  or  altogether 
absent,  except  at  the  right  apex,  where  the  \'oice  sounds  were  increased 
and  the  breathing  was  bronchovesicular. 

In  the  back,  with  the  patient  sitting  up,  there  was  relative  dulness 
down  to  a  point  i\  inches  below  the  angle  of  the  sca])ula,  the  line  of 
resonance  rising  from  that  point  obliquely  across  the  axilla  to  the  level 
of  the  third  rib  in  front.     Below  this  there  was  tympany. 

Over  the  dull  area  in  the  back  fremitus  is  diminished,  and  at  the 
extreme  base  absent.  Otherwise  the  signs  are  the  same  as  in  the  corre- 
sponding area  in  the  front.  There  are  no  rales,  no  friction  or  other  ab- 
normal sounds. 

Physical  examination  is  in  other  respects  negative.  The  blood  and 
urine  are  normal. 

Discussion. — As  we  read  the  signs  set  down  in  this  case,  pneumo- 
thorax is  naturally  our  first  thought.  But  can  pneumothorax  occur  so 
suddenly  in  a  person  of  excellent  health  and  without  any  of  the  known 
causes  of  pneumothorax  (phthisis,  trauma)?  Let  us  consider  the  other 
possibilities  before  answering  this  C|uestion. 

Pain,  dyspnea,  and  cough  suggest  })neumonia,  but  the  absence  of 
fever  and  of  any  e\'idence  that  the  patient  has  had  and  passed  a  crisis 
exclude  this. 

A  sharp  thoracic  pain,  followed  by  dyspnea  and  cough,  constitutes 
the  ordinary  onset  of  ])leurisy,  but  tlie  physical  signs  of  this  case,  especially 
the  tympany  at  the  base  of  the  chest,  together  with  the  absence  of  the 
friction  sounds,  exclude  this. 

Passing  to  other  possible  explanations  of  the  tympanitic  resonance 
just  referred  to,  we  think  of  emphysema;  but  this  cannot  be  so  localized, 


LUMBAR   PAIN  89 

and  is  never  of  sudden  onset.  The  j^resence  of  gas  below  the  diaphragm, 
either  in  the  bowel  or  in  an  abscess  cavity,  would  explain  many  of  the 
signs  in  this  case;  but  there  is  no  history  of  any  previous  abdominal 
symptoms,  such  as  usually  lead  to  the  so-called  subphrenic  pyopneumo- 
thorax. There  has  been  nothing  to  suggest  appendicitis,  ])erfo rating 
gastric  ulcer,  or  hepatic  abscess.  There  are  not  enough  fever  and  con- 
stitutional disturbance. 

We,  therefore,  return  to  the  first  supposition,  viz.,  pneumothorax. 
Investigation  of  any  large  number  of  cases  of  this  disease  shows  that 
its  symptoms  may  be  cither  stormy  and  virulent,  or  so  mild  as  to  be  prac- 
tically negligible.  Twice  I  ha\e  seen  pneumothorax  (proved  to  be  such 
by  the  liberation  of  air  through  puncture)  in  patients  who  felt  practically 
well  and  were  examined  almost  by  chance.  This  means  that  the  cause 
present  and  leading  to  the  vast  majority  of  all  cases  of  pneumothorax — 
namely,  tuberculosis — may  be  absolutely  latent  and  symptomless. 
This  is,  of  course,  a  well-known  fact,  but  the  sudden  appearance  of  a 
tuberculous  pneumothorax  brings  the  truth  home  to  us  in  a  startling 
way. 

Outcome. — The  patient  was  given  3  milligrams  of  tuljcrculin  after 
{we  days  of  normal  temperature,  and  the  temperature  thereafter  rose  to 
101°  F.  and  was  accompanied  by  headache  and  malaise. 

The  patient  was  accordingly  transferred  to  a  sanatorium  for  tuber- 
culosis. 

The  prognosis  in  a  case  of  this  kind  and  the  treatment  are  those  of 
the  underlying  process — ])hthisis.  The  advent  of  pneumothorax  docs 
not  render  the  outlook  much  gra\"er.  In  the  great  majority  of  cases  the 
air  is  readily  absorbed,  and  no  special  treatment  need  l)e  directed  to  it. 
If  the  air  persists  in  the  chest  unchanged  for  a  numljer  of  weeks,  or  if 
its  amount  is  so  large  as  seriously  to  embarrass  the  action  of  the  lu-art 
and  lungs,  it  may  be  remo\ed  In'  puncture,  after  which  it  may,  or  may 
not,  reaccumulate. 

Diagnosis. — Tubercular  pneumothorax. 

Case  24 

A  stationary  fireman  of  fifty  entered  the  hospital  November  q.  kjoi. 
Se\"en  years  ago,  following  an  injury  to  his  left  elbow,  the  joint  graduallx" 
grew  stiffer,  and  he  was  lokl  that  there  was  a  growth  ot  l)onc  there. 
He  came  to  the  out-patieiU  department  for  treatment,  and  the  ellmw 
\vas  baked  daih"  for  the  weeks,  with  consi(k'ral)k-  benefit,  l)ul  he  has 
nex'er  been  able  full}-  to  t'xtend  the  arm  since  that  time. 

Three  weeks  ago  he  l>egaii  to  ha\e  shooting  p;iin>  ;iiro><  tiie  >mall 


9©  DIFFERENTIAL   DIAGNOSIS 

of  his  back,  brought  on  by  any  motion.  Three  days  ago  these  pains 
became  so  severe  that  he  could  scarcely  move.  The  pain  now  starts 
in  the  small  of  the  back  and  extends  down  the  left  leg  as  far  as  the  ankle. 
Three  days  in  bed  has  given  him  no  relief. 

Physical  examination  showed  well-marked  Heberden's  nodes  on  the 
fingers.  The  physical  examination  was  otherwise  negative,  except  that 
the  left  elbow  could  not  be  flexed  beyond  80  degrees  or  extended  beyond 
45  degrees.  There  was  tenderness  along  the  back  of  the  left  thigh  from 
the  popliteal  space  to  the  sacrum,  also  o\-er  the  Achilles  tendon,  pressure 
on  which  causes  pain  to  shoot  up  the  thigh. 

So  long  as  the  patient  remained  absolutely  quiet  he  was  comfortable, 
but  coughing,  sneezing,  any  movement  of  the  leg  or  body  caused  pain  to 
shoot  from  the  sacrum  to  the  foot.  Fixation  with  a  ham  splint  afforded 
no  relief,  nor  did  the  application  of  cold  along  the  nerve.  Drugs  were 
without  effect.  Heat,  on  the  other  hand,  relie\'ed  him  somewhat. 
Tight  criss-cross  strapping  of  the  lower  back  and,  later,  a  supporting 
belt,  gave  still  more  relief,  although  numbness  of  the  thigh  and  calf 
developed  as  the  pain  diminished. 

Discussion. — The  great  majority  of  cases  of  pain  in  the  back  fall 
into  three  groups: 

1.  The  infectious  group. 

2.  The  orthopedic  group. 

3.  The  renal  grouj). 

The  first  and  the  last  of  these  may  be  excluded  by  the  absence  of 
fever  and  of  urinary  signs.  "Within  the  group  which  I  have  called  ortho- 
pedic fall  chiefly  lumbago,  sacro-iliac  strains  and  displacements,  spinal 
osteo-arthritis. 

Lumbago  is  pretty  definitely  excluded  by  the  long  duration  of  the 
disease.  After  three  weeks  of  pain  we  must  find  some  other  cause, 
especially  as  the  pain  is  no  longer  confined  to  the  lumbar  muscles,  but 
extends  down  the  left  leg. 

Sacro-iliac  disease  (strain,  sjjrain,  disjjlacement,  or  ])inching  of  joint 
fringes)  should  cause  the  ])atient  to  stand  with  a  list  to  one  side,  and 
should  produce  tenderness  over  the  sacro-iliac  joint,  together  with  [)ain 
increased  when  the  leg  is  raised  without  bending  the  knee.  Direct 
physical  examination  of  the  sacro-iliac  joint  usually  reveals  nothing  in 
these  cases  except  localized  tenderness.  In  this  case  the  above  tests  were 
all  negative. 

Spinal  osteo-arthritis  is  favored  by  the  age  of  the  patient,  and  by 
the  presence  of  similar  joint  outgrowths  elsewhere  (ell~)ow  and  fingers). 
Pain  on  couirhina;  and  sneezin"  is  also  rather  characteristic  of  osteo- 


LUMBAR   PAIN 


91 


arthritic  processes,  because  they  so  often  in\-ohe  the  costovertebral 
joints,  which  have  to  move  sharply  and  suddenly  when  we  cough  or 
sneeze.  This  symptom,  however,  also  occurs  in  all  the  orthopedic 
group  of  diseases  above  referred  to. 

Malignant  growths  in  or  near  the  spinal  column  might  account  for 
all  the  symptoms  here  present,  and  can  only  be  excluded  by  x-ray 
examination  or  by  the  outcome  of  the  case. 

Outcome. — X-ray  showed  osteo-arthritic  outgrowths  in  the  lower 
lumbar  region.  By  December  5th  he  was  able  to  walk  about  with 
crutches,  and  by  the  eleventh  he  was  able  to  go  home  very  much  relieved. 

Diagnosis. — Hypertrophic  spinal  arthritis. 

Case  25 

A  motorman  of  twenty-four  entered  the  hospital  August  19,  1907. 
His  habits  and  [)revious  history  were  good,  but  for  the  past  two  weeks 
he  has  had  pain  across  the  small  of  his  back.  For  the  past  four  days 
the  pain  across  the  small  of  his  back  has  become  more  severe  and  he  has 
been  nauseated  when  he  tried  to  eat,  although  he  has  felt  hungry. 

Six  days  ago  he  felt  chill}-  in  the  evening  and  sliivered  a  little;  but  he 
did  not  give  uj)  his  work  until  two  days  before  his  entrance  to  the  hosj)i- 
tal.  This  morning  he  had  a  brief  spell  of  tingling  in  the  left  arm.  He 
continues  to  feel  hungry,  but  cannot  eat.  He  does  not  feel  at  all  weak. 
His  bowels  move  once  daily. 

At  entrance  the  patient's  temperature  was  103.8°  F.;  pulse,  88; 
respiration,  24.  He  was  mentally  alert,  and  did  not  look  very  sick. 
There  was  a  harsh,  systolic  murmur  heard  all  over  the  ])recordia.  loudest 
in  the  jmlmonary  area,  where  there  is  a  suggestion  of  a  s}stolic  llirill. 
The  ])ulmonary  second  sound  was  sHghtly  greater  than  in  the  aortic. 
The  heart  shows  no  evidence  of  enlargement.  A  sliglulv  tender  mass 
was  felt  to  descend  below  the  left  costal  margin  on  full  inspiration. 

Physical  examination  was  otlierwise  negatixe.  The  urine  was  normal. 
The  \\'i(lal  reaction  was  negati\e;  the  white  cells  were  5400. 

Discussion. — The  presence  of  continued  fc\er  excludes  most  of  the 
so-called  orthopedic  group  discussed  in  the  last  case.  We  lia\'e  left 
the  infections,  local  and  general.  Local  infections  ])ro(lucing  pain  in  the 
back  are  cliietl}'  spinal  tuberculosis,  lu-matoL^u-nous  renal  infection,  and 
])erinephric  al)scess.  These  are  excluded  in  tlie  preseiU  ease,  because 
the  spine,  the  regicm  of  tlie  ki(liie\',  anteriorlv  and  ])osteriorl\'.  and  the 
urine,  are  all  negative.  We  are  left  with  the  ([uestion,  What  general 
infections  are  most  apt  to  cause  backache?  The  answer  is:  "griii." 
tonsillitis,    typhoid,   and    sepsis.     Of  tonsillitis  and   sepsis   we    ha\e  no 


92 


DIFFERENTIAL   DIAGNOSIS 


positive  c\-idence,  though  the  harsh  systoHc  murmur  mentioned  in  the 
text  might  suggest  a  sepsis  of  tlie  t3'ije  known  as  ulcerati\e  endocarditis. 
There  is,  however,  nothing  conclusive  about  this  murmur  as  described, 
and  nothing  else  in  the  case  to  support  the  diagnosis  of  sepsis.  The 
murmurs  most  suggestive  of  a  septic  endocarditis  are  those  that  rap- 
idly change  their  characteristics  under  observation,  especially  diastolic 
murmurs. 

The  good  appetite  and  the  mental  alertness  are  not  characteristic 
of  typhoid,  but  there  is  nothing  in  the  case  absolutely  inconsistent  with 
that  diagnosis.     The  tender  mass  felt  below  the  left  ribs  might  be  the 


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spleen.  The  absence  of  a  Widal  reaction  is  not  imusual  at  the  onset  of  a 
typhoid. 

In  the  absence  of  a  well-marked  infection  of  the  upper  air-passages 
with  the  influenza  bacillus  predominating  in  the  discharges  there  is 
never  any  good  reason  for  the  diagnosis  "grip."  Such  a  diagnosis  is 
usually  a  rather  cqui^•ocal  way  of  saying  ''T  don't  know."  The  word  is 
used  largely  to  satisfy  the  patient. 

On  the  e\"idcnce  thus  far  presented,  then,  one  can  only  guess  at  the 
diagnosis  of  this  case.  Only  as  the  chart  devclo])S  do  we  ])egin  to  feel 
any  more  confidence  that  our  original  guess,  tyjtlioid,  is  correct. 

For  treatment  see  Appendix. 

Outcome. — The   subsecjuent   course   of   the   temperature    is   shown 


LUMBAR    PAIN  93 

in  the  accompanying  chart.  The  Widal  did  not  appear  until  August 
25th.  The  mind  was  clear  and  alert  throughout,  and  after  the  twenty- 
eighth  the  mass  was  no  longer  felt  in  the  left  hypochondrium.  The 
patient  sat  up  on  the  twenty-second  of  September,  and  went  home  well 
on  the  first  of  October. 
Diagnosis. — Typhoid. 

Case  26 

A  widow  of  fifty  entered  the  hospital  March  17,  1908.  Her  history 
was  always  negative  up  to  a  month  previously,  when  she  began  to  ha\"e 
pain  in  her  lower  back  and  in  her  right  hip,  making  it  difficult  to  lie  down. 
The  pain  was  sharp,  constant,  and  increased  by  motion.  It  was  usually 
relieved  by  heat,  but  last  night  she  had  to  take  morphin  to  get  to  sleep. 
She  has  worked  until  four  days  ago,  though  her  appetite  has  been  poor, 
and  she  has  some  nausea  and  loss  of  weight. 

On  the  right  back,  on  a  line  with  the  spine  of  the  ilium,  is  a  group  of 
broken  vesicles  covering  an  area  of  2]  inches  by  one  inch,  and  extending 
at  right  angles  to  the  spinal  column.  Tem[)erature,  pulse,  and  resjnra- 
tiop  normal. 

Dr.  R.  B.  Osgood  found  nothing  wrong  in  the  bones  and  joints. 
Vaginal  examination  was  negati\'e,  as  were  the  blood  and  the  urine. 
Dr.  James  J.  Putnam  considered  the  pain  due  to  herpes.  She  slept  well 
on  the  night  of  the  twenty-first  after  10  grains  of  veronal,  and  aspirin  in 
doses  of  10  grains  also  relieved  her.  Acetanilid  5  grains  with  2  grains  of 
caffein  was  later  given  to  insure  sleep.  Aconitin  in  0^77  to  y^^  grain 
doses  had  no  effect,  although  it  was  pushed  up  to  the  point  of  toxic 
symptoms,  when  she  remarked  that  it  made  her  feel  cold  and  clammy, 
like  a  chicken  just  taken  ofi"  the  ice.  I>ater  her  ])ain  became  more  se\erc, 
and  was  not  relieved  either  by  aspirin,  by  quinin,  or  by  strychnin.  Phe- 
nacetin  and  salol  relieved  her  more,  and  by  the  sixteenth  of  April  she 
was  able  to  sleep  without  any  drugs  at  night.  \'eronal  and  codein,  the 
former  10  grains,  the  latter  half  a  grain,  were  repeatedly  needed  before 
April  loth  for  slecj). 

After  she  had  ])een  In  the  ward  five  weeks  witli  normal  tcm])eratiire 
and  pulse  throughout,  her  temperature  suddenly  rose  to  10:;. 5^  I*".,  and 
her  leukocytes,  which  had  previousl}'  l)een  normal,  rose  to  i<).2oo. 

The  lungs  were  negati\"e,  but  there  was  marked  tfiKkTiicss  in  thi- 
right  lower  abdomen,  witliout  s]»asm.  M1k' patient  was  so  liypcrMMi-itiNc 
\' hen  slie  was  touched  at  auN'  j)oint  that  it  was  (liflicult  to  l^lll>^\  ho>\- 
nnich  weigjit  to  la}-  u])on  her  abdominal  pain. 

I)V  the  twentv-fifth  [he  teniDcraturc  had  a^ain  n-aclu'd  noi'iual;  the 


94  DIFFERENTIAL   DIAGNOSIS 

white  cells  were  still  above  15,000,  and  there  was  indefinite  sensitive- 
ness in  the  right  lower  quadrant. 

On  the  twenty-ninth,  after  she  had  been  sitting  up,  she  appeared 
to  be  very  sensitive  in  the  right  iliac  fossa. 

Discussion. — Lumbar  pain  without  fever  and  without  evidence  of 
any  disease  of  the  orthopedic  group  or  of  the  kidney  group  should 
always  suggest  the  possibility  of  a  neuritis.  The  group  of  vesicles, 
though  covering  so  limited  an  area,  gives  strong  support  to  the  hypothesis. 
Neuritis  of  the  thoracic  region,  involving,  presumably,  in  every  case  a 
lesion  of  the  spinal  ganglion  corresponding,  is  especially  apt  to  l^e 
accompanied  by  that  \'esicular  eruption  which  we  call  herpes  zoster  or 
"shingles."  In  the  majority  of  cases  the  painful  area  is  much  larger 
that  the  vesiculated  area.  It  need  not  surprise  us,  then,  that  in  this  case 
the  vesicles  co\"er  such  a  small  spot,  and  we  have  no  good  reason  to 
hesitate  regarding  the  diagnosis — herpes  zoster.  Presumably  this  is 
due  to  a  local  infection  of  the  spinal  ganglion  similar  to  that  which  has 
been  demonstrated  in  the  ganglia  corresponding  to  the  facial  herpes  in 
pneumonia. 

Regarding  the  treatment  of  this  painful  affection,  it  is  worth  noting 
that  the  application  of  an  ethyl  chlorid  spray  over  the  corresponding 
spinal  ganglion  sometimes  gives  very  striking  relief  to  the  pain. 

Can  the  abdominal  pain,  occurring  in  the  sixth  week  of  this  case,  be 
attributed  to  a  second  attack  of  the  same  trouble?  Experience  has 
taught  us  ne\er  to  multiply  causes  or  diagnoses  if  the  facts  can  be  ex- 
plained otherwise.  But  in  this  case  the  occurrence  of  fe\er  and  leuko- 
cytosis, with  the  new  pain,  should  make  us  look  for  some  local  in- 
flammatory cause.  We  should  search  for  evidence  of  a  local  abscess, 
of  tonsillitis,  of  phlebitis,  arthritis,  or  pneumonia.  By  the  twenty-ninth, 
when  tenderness  in  the  right  iliac  fossa  was  marked,  there  seemed  to  be 
every  reason  to  susj^ect  the  appendix. 

Outcome. — On  the  second  of  ]May  the  white  cells  had  risen  to  31,000, 
and  a  distinct  mass  could  be  felt  in  the  right  iliac  region. 

On  May  3d  the  abdomen  was  opened  and  an  ounce  of  })us  evacuated 
from  the  region  of  the  apr)endix. 

The  patient's  recovery  was  complete. 

This  case  constitutes  one  of  those  exceptions  which  prove  the  rule — 
the  rule,  namely,  that  we  do  not  often  deal  with  two  diseases  as  the 
explanation  for  a  group  of  sym])toms.  In  the  light  of  the  findings  at 
operations  wc  naturally  ask  oursehes  whether  the  whole  thing,  from  start 
to .  finish,  might  not  have  been  due  to  appendicitis.  I  should  answer 
decidedly,   "No."     The  location  of  the  original  pain,  the  absence  of 


LUMBAR   PAIN  95 

fever,  and  the  presence  of  the  vesicular  eruption  seem  to  me  to  make 
this  supposition  impossible,  though  it  is  conceivable  that  there  may  ha\e 
been  a  common  cause  both  for  the  zoster  and  the  subsequent  appendi- 
citis. 

Diagnosis. — Appendicitis;  herj^es  zoster. 

Case  27 

A  married  woman  of  twenty-one  had  ''grip"  three  times  last  winter, 
but  has  otherwise  been  well  until  two  weeks  ago,  when,  after  her  last 
attack  of  "grip,"  she  began  to  have  pain  in  her  back,  and  to  a  less  extent 
in  her  arms,  chest,  and  knees,  without  any  limitation  to  the  movement 
of  the  joints.  For  the  past  week  she  has  been  in  bed,  l)ut  for  the  past 
two  nights  she  has  slept  litde  on  account  of  pain  in  the  l^ack. 

When  the  patient  was  first  seen,  ]March  26,  1908,  her  temperature  was 
101°  F.,  pulse,  no,  and  respiration,  25. 

The  temjjerature  remained  elevated  for  four  days;  after  that  it  was, 
for  the  most  part,  normal.  The  action  of  the  heart  was  regular  and  rapid, 
with  a  gallop  rhythm.  The  pulmonic  second  sound  was  accentuated, 
and  the  first  sound  at  the  aj)ex  was  accompanied  Ijy  a  rough  s}stolic 
murmur  heard  all  over  the  [)recordia  and  in  the  axilla.  There  Wcis  no 
obvious  enlargement  of  the  organ.  Physical  examination  was  otherwise 
negative,  except  that  the  white  cells  numbered  16,300. 

Rest  in  bed,  10  grains  of  salicylate  of  strontium  every  four  hours,  with 
an  ice-bag  over  the  precordia,  an  occasional  A.  S.  and  B.  pill,  and  an 
occasional  I,  grain  of  morphin,  gave  her  relief  within  a  few  days.  Later, 
she  comjjlained  of  piercing  ])ains  in  the  precordia,  which  made  her  \"er}- 
nervous.     Xolhing  was  found  there  on  physical  examination. 

Discussion. — I  ha\e  included  this  case  because  it  seems  best  that 
my  book  should  mirror  some  of  the  most  annoying  defects  of  our  ])resent 
knowledge,  as  well  as  its  strong  points.  This  is  the  sort  of  case  which 
is  ordinarily  called  "grip"  at  the  start,  while  we  watch  for  (levflo])ments. 
If  none  come,  the  diagnosis  is  formally  confirmed. 

For  what  other  possil)ilities  should  we  be  on  the  watch  in  a  case  of 
this  kind?  Endocarditis,  first  of  all,  on  account  of  the  cardiac  murnuir, 
the  leukocytosis,  and  the  early  joint  pains.  Only  the  disappearance  of 
these  symptoms  with  the  lapse  of  a  few  days  excludes  endtnarditis. 

Typhoid  is  made  practically  impossil)le  by  the  presence  o!  \Nelb 
marked  leukocytosis. 

As  T  have  already  said  in  the  discussion  of  pre\i()us  cases.  1  think 
"luiknown  infection"  should  be  our  \erdict.  It  is  time  to  droj)  the 
ecpiivocal  use  of  the  word  "grip"  as  a  cloak  for  our  ignorance. 


96  DIFFERENTIAL   DIAGNOSIS 

It  is  worth  noting  that  the  use  of  an  ice-bag  over  the  precordia  very 
probably  accounted  for  a  good  deal  of  the  patient's  later  suffering.  It 
drew  her  attention  to  the  possibility  of  heart  trouble.  In  a  nervous 
person  this  is  enough  to  produce  heart  pains. 

Outcome. — Nervousness  was  throughout  a  prominent  feature,  but 
by  the  sixteenth  of  April  she  was  nearly  well,  and  was  discharged  to 
finish  her  convalescence  at  home. 

Diagnosis. — Unknown  infection. 

Case   28 

A  night  watchman  of  sixty-nine  entered  the  hospital  January  31, 
1907,  complaining  that  when  he  got  up  two  days  before  he  "felt  his  hip 
catch."  Within  three  hours  he  was  unable  to  bear  any  weight  on  the 
left  foot  and  went  back  to  bed.  The  pain  has  continued  since,  and  he 
has  been  helpless. 

On  physical  examination  it  was  found  that  any  motion  of  the  left 
hip  or  back  caused  exquisite  pain.  There  was  some  tenderness  at  the 
upper  point  of  exit  of  the  nerve.  Physical  examination  otherwise  nega- 
tive. Temperature  oscillated  between  98°  and  101.4°  F.  for  four  days, 
then  normal.     \Miites,  8000. 

Flexion  of  the  thigh,  with  the  knee  kept  straight,  caused  pain  referred 
to  the  left  sacro-iliac  joint. 

Discussion. — Can  the  symptoms  be  due  to  strain  of  the  back? 
What  tests  should  be  employed  to  confirm  or  exclude  the  diagnosis  of 
lumbago,  of  sacro-iliac  disease,  of  hip  disease,  of  spinal  osteo-arthritis? 
What  further  data  are  necessary? 

In  answer  to  these  questions  I  should  say  that  it  is  wholly  unlikely 
that  strain  entered  into  the  causation  of  these  symptoms,  since  the  pain 
was  first  felt  after  the  blameless  action  of  getting  out  of  bed. 

For  lumbago  the  main  tests  are  for  the  production  of  pain  by  any  use 
of  the  lumbar  muscles,  together  with  the  absence  of  any  disease  of  the 
bone  or  kidney. 

In  relation  to  sacro-iliac  disease  we  should  endeavor  to  ascertain 
whether  the  patient  stands  with  a  list  to  the  other  side,  whether  the 
pain  and  tenderness  are  referred  especially  to  the  sacro-iliac  joint  when 
the  thigh  is  flexed  with  the  knee  straight,  whether  there  is  any  sacro-iliac 
pain  on  compressing  the  wings  of  the  ilium. 

The  therapeutic  test,  the  effect  of  attempting  to  immobilize  the 
ioint  by  strapping  or  otherwise,  is  also  of  importance.  Hip-joint 
disease  is  to  be  excluded  in  case  the  motions  at  that  joint  are  really 
free. 


LUMBAR   pain: 


97 


Osteo-arthritis  is  difficult  to  exclude  or  to  identify  positively.  We 
suspect  it  in  the  presence  of  long-standing  lumbar  pain  associated  with 
radiations  along  the  thoracic,  lumbar,  and  sciatic  nerves,  aggravated 
if  when  the  muscular  protection  is  relaxed  in  sleep,  the  patient  at- 
tempts to  turn  over.  It  is  aggravated  also  by  coughing  and  sneezing. 
An  vT-ray  picture  and  the  exclusion  of  sacro-iliac  disease  complete  our 
task. 

The  present  case  offers  a  fairly  characteristic  picture  of  what  is 
ordinarily  known  as  sacro-iliac  sprain  or  strain.  The  pathology  of  this 
affection  is  still  very  obscure.  It  may  be  that  one  of  the  joint  fringes 
gets  pinched  owing  to  slight  relaxation  or  subluxation  of  the  joint  when 
the  muscular  or  ligamentous  protection  is  imperfect.  A  person  becomes 
debilitated  or  tired,  muscularly  or  nervously.  His  muscles  are  no 
longer  as  alert  and  well  toned  for  protection  as  they  should  be.  A  slight 
slip  occurs,  and  a  joint  fringe  or  some  other  sensitive  joint  structure  is 
impinged  upon.  If  this  were  true,  it  would  explain  the  frequent  asso- 
ciation of  the  trouble  with  neurasthenic  and  debilitated  states. 

Outcome. — The  patient  was  considerably  relieved  by  lo  grains  of 
aspirin  every  four  hours  and  tight  cross-strapping  of  the  back  and  hip. 
He  was  able  to  leave  the  hospital  by  the  twenty-fifth  of  February. 

Diagnosis. — Sacro-iliac  strain. 

Case  29 

A  nurse  of  thirty-six  who  had  previously  suffered  from  dysentery 
when  nursing  in  the  Philippines,  entered  the  hospital  March  21,  1908, 
complaining  that  for  the  past  four  months  she  had  had  pain  in  the  lower 
part  of  her  back,  extending  down  the  right  leg.  She  has  also  had  swelling 
of  the  right  foot  and  stiffness  of  the  neck  off  and  on  during  these  four 
months.  The  pain  is  somewhat  relieved  by  heat,  but  she  has  had  to 
have  morphin  pretty  continuously  in  order  to  keep  her  comfortalile. 

She  has  been  unable  to  work  since  the  previous  December,  and  has 
lost  20  pounds  in  the  past  five  weeks. 

On  physical  examination  the  thyroid  gland  was  found  to  be  slightly 
enlarged.  Temperature,  ])ulse,  and  respiration  were  normal,  the  chest 
and  abdomen  negative.     Urine  normal. 

The  pulsations  of  the  aorta  were  \'iolent  in  the  epigastrium.  The 
knee-jerks  were  extremely  li\'ely,  but  there  was  no  clonus  and  no  Babin- 
ski.     Ooss-straj)ping  gave  her  a  great  deal  of  relief. 

Discussion. — Here  is  a  long-standing  ])ain  which,  in  a  woman  of 
thirty-six,  sliould  make  us  consider  Pott's  disease  and  cancer;  but  ex- 
amination shows  no  evidence  of  either  of  these  troubles,  and  a  denser 


98 


DIFFERENTIAL  DIAGNOSIS 


study  of  the  case  shows  two  causes  whereby  the  duration  of  the  pain  may 
well  have  been  inordinately  prolonged.  I  refer  to  the  use  of  morphin 
and  to  the  evidence  of  a  hypersensitive  temperament,  shown  in  the 
exaggerated  knee-jerks  and  the  violent  pulsation  of  the  abdominal  aorta. 
Coming  then  to  the  milder  possibilities,  we  should  naturally  think  of 
lumbago,  because  the  patient  has  also  suffered  from  stiff  neck  (so  often 
associated  with  lumbago).  The  duration,  however,  is  somewhat  too 
great.     She  should  have  been  relieved  by  rest  within  a  week  or  two. 

The  pain  extends  down  the  right  leg,  and  is  accompanied  by  swelling 
of  the  right  foot.  Can  it  be  due  to  neuritis?  There  were  no  nerve 
tenderness  and  no  disturbance  of  sensation.  The  ordinary  tests  for 
sacro-iliac  disease  (see  above)  were  positive. 

Outcome. — Dr.  Goldthwait  saw  the  case  in  consultation  and  made 
a  diagnosis  of  chronic  strain  in  the  right  sacro-iliac  joint. 

Diagnosis. — Sacro-iliac  strain. 


Case  30 

A  school-girl,  eight  years  of  age,  entered  the  hospital  May  26,  1908, 
complaining  of  dull,  constant  pain  in  the  right  side  of  the  lower  back, 

Vv'orse  at  night,  accompanied  by 
fever,  vomiting,  and  constipation. 
Her  bowels  have  not  moved  for  four 
da}-s.  There  has  been  no  injury  to 
the  back,  no  cough,  and  no  chill. 
Family  history  and  previous  history 
are  negative. 

Physical  examination  showed  a 
herpes  on  the  lips.  Nothing  ab- 
normal was  found  in  the  chest  or 
abdomen  except  for  a  general  ten- 
derness, especially  marked  in  the 
costovertebral  angles  and  in  the 
flanks. 

The  urine  showed  a  large  amount 
of  pus,  and   the  culture  revealed  a 
characteristic  growth  of  colon  bacilli. 
The  temperature  remained  abo\'e 
101°  F.  for  a  week.      (See  accom- 
panying chart.)      The  patient  was  at  first  very  sick,  with  a  white  count 
of  24,000,  82  per  cent,  of  the  cells  being  polynuclear. 

Any  lumbar  pain  with  fever  in  a  small  girl  suggests  Pott's  disease. 


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LUMBAR   PAIN 


99 


This  being  excluded  by  the  absence  of  any  kyphos  or  muscular  spasm 
about  the  spine,  we  have  next  to  note  that  the  patient  is  rather  young 
for  any  of  the  orthopedic  group  of  diseases. 

If  it  is  an  infection,  as  the  fever  suggests,  is  it  local — that  is,  renal  or 
perirenal — or  is  it  general?  The  condition  of  the  urine  and  the  leuko- 
cytosis point  strongly  to  a  local  urinary  infection. 

Outcome. — The  leukocyte  count  fell  to  normal  along  with  the  tem- 
perature. The  treatment  consisted  of  alcohol  sponges  at  80°  F.  every 
four  hours;  urotropin,  4  grains,  three  times  a  day,  an  abundance  of 
water  to  drink,  and  a  liquid  diet. 

By  the  eleventh  of  June  the  urine  was  nearly  normal  and  the  child 
practically  well. 

In  view  of  the  rapidly  favorable  outcome  in  this  case  tliere  was  no 
need  for  any  attempt  further  to  verify  the  diagnosis  by  cystoscopy  or 
ureteral  catheterization. 

The  renal  infections,  among  which  the  hematogenous  are  not  always 
to  be  distinguished  from  the  ascending  affections,  may  be  subdivided  into 
the  following  four  groups: 

1.  Those  presenting  in  girl  babies  or  young  girls  an  apparently 
unaccountable  fever,  without  anything  to  suggest  its  source.  It  is  not 
always  easy  in  these  cases  to  collect  and  examine  the  urine,  hence  this 
most  important  clue  is  often  neglected.  The  presence  of  a  moderate 
or  considerable  number  of  leukocytes  in  the  sediment  of  such  a  urine, 
when  vaginal  contamination  is  excluded,  strongly  suggests  a  urinary 
infection.  A  pure  culture  of  colon  bacilli  can  usually  be  obtained  from 
the  urine,  as  it  was  in  this  case,  and  the  thera])cutic  test  (rapid  impro\'e- 
ment  under  forced  water-drinking  and  urotropin)  puts  the  diagnosis 
upon  a  fairly  firm  foundation. 

2.  In  other  persons  the  disease  often  sets  in  in  an  acute  and  tiireat- 
ening  way,  like  apjx'ndicitis  or  acute  cholecystitis.  Fever,  leukocytosis, 
pus  in  the  urine,  and  tenderness  in  the  costovertebral  angle  are  a  very 
suggestive  group  of  sym})toms  and  demand  cystoscopy  as  confirmation. 
Nephrotomy  or  ne])hrectomy  may  be  necessary  to  save  life  if  the  S}m]i- 
toms  do  not  ra])idly  abate  after  the  ingestion  of  urotropin  and  large 
amounts  of  water. 

3.  Relatively  mikl  and  clironic  cases,  characterized  by  pyuria,  with 
wa\es  of  irregular  fe\er  and  ])()ssibly  some  bladder  symptoms,  often 
occur  in  women  Ijcfore  or  after  ])arturition.  In  some  of  these  chronic 
cases  the  urotro])in  and  ^^•ater  treatment  may  be  assisted  by  the  use  of 
a  A'accine  ])re])are<l  from  the  organism  isolated  from  ilie  urine — almost 
always  the  colon  bacillus. 


ICX3 


DIFFERENTIAL  DIAGNOSIS 


4.  There  seems  to  me  to  be  good  reason  to  believe  that  most,  if  not 
all,  cases  of  perinephric  abscess  represent  neglected  forms  of  the  hema- 
togenous infections  just  classified.  It  is  a  notable  fact  that  in  the  past 
two  years,  since  our  attention  was  called  to  the  frequency  of  hematogen- 
ous renal  infections  by  the  papers  of  Brewer  and  Cobb,  the  number  of 
cases  of  perinephric  abscess  has  greatly  diminished. 

In  my  opinion  there  is  no  longer  any  ground  for  supposing  that  a 
primary  pyelitis,  distinct  from  ascending  infections,  exists  at  all.  It  has 
neither  a  pathologic  nor  a  clinical  basis. 

Diagnosis. — Renal  infection,  hematogenous  or  ascending. 

Case  31 

A  waitress  of  twenty-six,  of  good  family  history  and  previous  history, 
entered  the  hospital  January  30,  1908.  Up  to  yesterday  morning  she 
had  been  well.     She  then  was  seized  with  pain  in  the  right  lumbar 

region  and  lower  back.  This  pain 
has  persisted  and  become  worse  ever 
since.  She  has  vomited  a  clear  liquid 
several  times,  and  has  had  some 
cough,  with  thick  white  sputum.  She 
has  no  abdominal  pain,  but  consider- 
able headache. 

Physical     examination     showed 
many  papules  scattered  over  the  en- 
tire  body.     The    conjunctivae  were 
injected  and  watery;  the  breath  offen- 
sive.  At  the  angle  of  the  right  scapula 
the  respiration  was  slightly  dimin- 
ished, and  the  whisper  slightly  in- 
creased.     The    right    kidney    was 
doubtfully  felt,  and  there  was  some 
tenderness  there,  but  more  marked 
tenderness    under   the    risfht    costal 
border  and  in  the  right  iliac  fossa. 
The  general  abdominal  tenderness  was  so  marked  that  the  patient 
was  seen  by  a  surgical  consultant  who,  however,  found  no  evidence  of 
peritonitis.     The  urine  was  negative. 

The  temperature  ranged  for  seven  days  above  101°  F.  fsee  accom- 
panying chart),  and  the  white  count  between  13,000  and  15,000.  The 
chest  was  strapped,  with  very  slight  relief. 

Discussion. — An  acute  lumbar  ])ain,  accompanied  by  fever,  head- 


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Fig.  15. — Chart  of  case  31. 


LUMBAR    PAIN  1 01 

ache,  leukocytosis,  cough  and  some  tenderness  about  the  right  kidney, 
suggests  several  possibilities. 

1.  Since  the  pain  began  upon  the  right  and  is  accompanied  by  some 
tenderness  in  the  region  of  the  right  kidney,  a  renal  infection  must  be 
considered,  especially  as  the  right  kidney  is  far  more  often  affected  than 
the  left  by  such  infections.  But  in  the  presence  of  a  negative  urine  all 
the  other  possibilities  must  first  be  carefully  canvassed  before  proceeding 
to  cystoscopy  or  any  such  bothersome  tests. 

2.  The  orthopedic  group  of  troubles  seems  unlikely  in  view  of  the 
acute  febrile  onset  and  the  absence  of  confirmatory  tests. 

3.  Against  the  diagnosis  of  local  peritonitis  (gall-bladder,  appendix, 
perforating  gastric  ulcer)  is  the  entire  absence  of  muscular  spasm  and 
the  very  wide  area  of  tenderness. 

4.  Despite  the  exclusion  of  all  these  possibilities,  the  diagnosis  re- 
mained uncertain.  The  rather  doubtful  signs  at  the  base  of  the  right 
lung  were  sufficient,  however,  to  make  us  examine  this  part  very  fre- 
quently in  anticipation  of  the  possible  development  of  pneumonia.  So 
many  cases  beginning  with  abdominal  symptoms  have  ultimately  turned 
out  to  be  pneumonia,  escaping  laparotomy  narrowly,  if  at  all,  that  we  are 
always  on  the  watch  for  such  an  event. 

Outcome. — On  February  2d  the  signs  of  solidification  finally  ap- 
peared at  the  right  base.  Abdominal  distention  and  tenderness  were 
marked.  The  patient  had  a  crisis  on  the  evening  of  the  sixth  of  Feb- 
ruary, and  by  the  fourteenth  was  out  of  bed  and  convalescent,  though 
loud  pleural  friction,  entirely  unaccompanied  by  pain,  persisted  from 
the  eleventh  of  February  until  her  discharge  from  the  hospital  on  the 
sixteenth. 

It  is  a  familiar  and  a  puzzling  experience  that  many  infections, 
especially  pneumonia,  cholecystitis,  and  appendicitis,  begin  with  vague 
general  symptoms  (fever,  wide-spread  pains,  chills,  vomiting)  before 
settling  down  to  business  in  any  discovera]:)le  locality.  Looking  back 
over  the  course  of  such  a  chain  of  events,  after  the  ])neumonia  or  the 
ap])endicitis  has  been  found,  we  arc  apt  to  suj)|)ose  that  the  local  trouble 
was  really  there  all  the  time.  The  weight  of  e\"i(lence,  hc)\vc\er,  seems 
to  me  to  point  the  other  way.  The  local  manifestation  of  an  infection  is 
often,  I  lx'lie\e,  a  late  event  in  fact,  as  well  as  in  our  diagnoses. 

Diagnosis. — Pneumonia. 

Case  32 

A  married  woman  of  thirty  entered  tlie  hos])ital  October  27,  tSqo. 
Four  and  a  half  vears  a^o  she  had  had  a  misearriatzi-',  incluce<l  bv  the 


I02 


DIFFERENTIAL  DIAGNOSIS 


introduction  of  a  sound  into  the  uterus,  and  a  second  miscarriage,  with- 
out known  cause,  four  years  ago.  Otherwise  than  this  she  had  been 
always  well  until  seven  weeks  ago,  when  she  was  taken  with  severe  pain 
in  the  small  of  the  back,  which  has  lasted  ever  since,  and  which  extends 
at  times  to  the  front  of  the  abdomen.  Her  bowels  are  very  costive, 
moving  about  once  in  five  days.  The  pain  in  her  back  is  not  affected 
by  motion,  but  has  been  severe  enough  to  confine  her  to  bed  for  the  first 
two  weeks  of  her  sickness.  Since  that  time  she  has  been  up  part  of 
each  day,  but  has  gained  very  little  in  strength,  and  has  lost  20  pounds 
in  weight.  The  range  of  temperature  and  pulse  are  seen  in  the  accom- 
panying chart.  The  right  lobe  of  the 
thyroid  gland  is  palpable,  and  seems 
about  the  size  of  a  plum.  The  patient 
has  noticed  this  lump  for  several  months, 
and  says  that  it  varies  greatly  in  size,  at 
times  being  scarcely  palpable. 

The  chest  shows  nothing  abnormal. 
The  abdomen  shows  slight  general 
resistance  and  considerable  general 
tenderness,  the  latter  most  marked  in 
the  left  iliac  fossa.  Motions  of  the  back 
are  limited  in  all  directions  by  muscular 
spasm,  and  seem  to  cause  pain,  es- 
pecially when  she  bends  to  the  right. 
Pelvic  organs  normal. 

Examination  of  the  stomach  through 

a  tube   shows    a    capacity  of  only  16 

ounces.     The    position    of    the    organ 

after  distention  with  air  was  a])parently 

normal.     After  a  test-meal  the  stomach-contents  showed  o.i  per  cent. 

of  free  HCl,  no  lactic  acid,  and  no  blood. 

In  the  course  of  two  weeks  all  the  pains  disappeared.  Dr.  Gold- 
thwait  found  no  lesion  of  the  spine,  hip,  or  pelvic  joints.  A  firm  binder 
about  the  hips  gave  no  relief.  Tonics,  sodium  bromid,  enema ta,  and 
hypnotics  were  given  for  the  control  of  symptoms  as  they  appeared  from 
time  tc  time. 

By  the  eleventli  of  November  the  patient  seemed  nearly  well. 
Discussion. — The  case  is  afebrile,  and  apparently  not  of  the  renal 
or  orthopedic  groups.     The  pain  is  not  affected  by  motion  and,  there- 
fore, is  not  due  to  lumbago.     There  is  no  evidence  of  sacro-iliac  or  spinal 
disease.     The  most  definite  and  important  feature  in  the  case  is  the  fact 


tei*   i-;  2i  LA  JD  J/    1  ^  .,  V   s-  i   7  i-c.    If  If 

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Pig.  16. — Chart  of  case  32. 


LUMBAR   PAIN 


103 


that  the  woman  is  debilitated,  has  lost  20  pounds  in  weight,  is  badly 
constipated,  and  probably  has  a  wide-spread  depression  of  other  func- 
tions. There  is  no  reason  to  suppose  that  the  thyroid  enlargement  has 
any  bearing  on  the  symptoms. 

Nothing  certain  can  be  said  regarding  the  diagnosis  of  such  a  case 
until  the  lapse  of  some  time  has  made  it  clear  that  nothing  else  is  going 
to  develop.  After  this  we  may  settle  down  more  or  less  discontentedly, 
with  the  diagnosis  of  what  some  orthopedic  specialists  call  a  "  functional 
back."  This  is  a  very  familiar  clinical  entity,  whatever  its  real  cause 
and  best  nomenclature  may  be. 

Two  things  seem  to  me  clear  about  this  trouble:  first,  that  psychic 
causes  enter  into  it,  and,  second,  that  they  are  not  the  whole  of  it.  For 
example,  I  have  seen  a  young  woman  drag  herself  painfully  down  the 
street  to  the  post-office  with  lumbar  pain  at  every  step,  while  each  foot 
seems  to  weigh  a  ton  and  every  muscular  contraction  is  an  effort.  She 
calls  at  the  post-office,  gets  a  certain  kind  of  letter,  and  walks  home 
erect  and  free  from  pain.  We  are  apt  to  say  that  such  symptoms 
are  imaginary,  but  this  seems  to  me  wholly  unscientific.  Certainly 
psychic  causes  enter  powerfully  into  their  production  and  destruction. 
May  we  not  plausibly  suppose  that  discouragement  has  slackened  the 
muscles  as  it  does  those  of  a  tired  army  on  the  march?  A  psychic  cause 
renders  them  taut — a  band  of  music,  a  long-expected  letter;  they  there- 
upon begin  to  support  the  sagging  joints,  and  the  pain  disappears  as 
sensitive  parts  are  relieved  of  pressure.  It  is  in  cases  of  this  type  that 
practitioners  are  apt  to  seek  a  cause  for  the  symptoms  in  the  pelvis, 
with  what  scanty  justification  I  have  endeavored  to  show  in  the  intro- 
duction to  this  chapter. 

Diagnosis. — Debility. 

Case  33 

A  metal  polisher  of  thirty-six  entered  the  hospital  June  24.  1908, 
because  of  |)ain  in  the  l)ack,  ])eneath  the  twelfth  ril:),  on  both  sides. 
This  yrn'm  had  been  ])resent  for  one  week  before  entrance,  accom])anied 
by  fever  for  the  jmst  four  days,  and  vomiting  for  the  })ast  three  days. 
Ten  days  ago  micturition  was  frequent  and  painful  for  one  da}'  and  the 
urine  bloody. 

The  urine  at  entrance  showed  much  pus,  a  little  blood,  ;i  slight  trace 
of  albumin.  The  s])ecific  gravity  varied  between  100:;  and  10 10. 
Tlie  twenty-four-hour  amount  was  from  80  to  too  ounces  a  day.  .\n 
occasional  granular  cast  was  found  in  the  sediment.  Tlie  li'ukdcytes 
ranged  from  16,000  to  19,000  ])er  cubic  milHmctcr.     \\'idars  reaction 


I04 


DIFFERENTIAL  DIAGNOSIS 


was  negative;  the  range  of  the  temperature  and  pulse  was  as  seen  in  the 
accompanying  chart. 

On  physical  examination  the  man  was  emaciated,  pale,  with  sunken 
eyes.  The  edge  of  the  spleen  was  easily  felt.  Physical  examination 
was  otherwise  negative,  except  for  considerable  tenderness  in  both 
costovertebral  angles.  On  the  second  of  July  a  macular  erythema 
appeared  upon  the  back  of  the  trunk  and  hands,  and  was  seen  by  Dr. 
Charles  J.  White,  who  stated  that  he  could  not  definitely  recognize  the 
nature  of  these  macules.  His  bowels  were  moved  by  calomel  and 
enemata,  and  he  was  given  liquid  diet.  A  culture  specimen  of  urine 
showed  a  pure  grov/th  of  colon  bacilli.     By  the  thirteenth  of  July  pus 

had  disappeared  from  the  urine.  The 
white  cells  were  8700.  The  Widal  re- 
action was  negative,  as  it  was  throughout 
the  illness. 

Discussion.  —  The  symptoms  point 
obviously  to  the  kidney,  but  the  enlarge- 
ment of  the  spleen  suggests  the  possibility 
of  some  other  cause  for  the  fever.  With 
such  a  urine,  with  costovertebral  tender- 
ness and  leukocytosis,  a  urinary  infection 
must  form  at  least  a  partial  explanation 
of  the  symptoms.  Owing  to  the  persis- 
tence of  fever  and  the  splenic  enlargement, 
a  routine  blood-culture  was  taken,  which, 
to  everyone's  surprise,  showed  typical 
typhoid  bacilli.  In  view  of  this  fact  it  may 
well  be  questioned  whether  the  macular 
erythema  was  not,  in  fact,  due  to  some 
form  of  typhoid  rose  spot— in  other  words, 
whether  it  was  not  due,  like  the  ordinary  crop  of  rose  spots,  to  the 
lodgement  of  typhoid  bacilli  beneath  the  skin. 

Evidently  we  were  dealing,  in  this  case,  with  a  double  infection,  both 
typhoid  bacilli  and  colon  bacilli  being  active  pathogenic  agents.  The 
colon  bacilli,  in  process  of  elimination  from  the  body,  presumably  caused 
the  renal  infection.  The  lumbar  pain  was  probably  of  the  general 
infectious  type,  and  not  due  to  kidney  lesion. 

Outcome. — The  patient  was  given  urotropin,  yh  grains  three  times 
a  day,  and  left  the  hospital  well  on  the  twenty-sixth  of  July. 
Diagnosis. — Typhoid  and  colon  bacillus  infection. 


Fig.  17. — Chart  of  case  23- 


LUMBAR   PAIN 


Case  34 


105 


A  laborer  of  thirty-Bine  entered  the  hospital  June  11,  1907, 
In  1899  he  wrenched  his  back  in  lifting  a  heavy  jack,  and  was  lame 
for  three  or  four  weeks  afterward.  In  February,  1906,  he  had  sciatica. 
For  the  past  two  months  he  has  noticed  an  ache  in  his  back  when  he 
gets  up  in  the  morning.  Ten  days  ago  he  noticed  tingling  and  numbness 
in  his  toes  and  the  pain  in  his  back  increased.  Since  then  he  has  slept 
very  little,  and  six  days  ago  he  had  to  have  morphin,  which  has  been 
frequently  used  since  then,  but  lately  with  only  slight  relief. 

Both  legs,  from  the  knees  to  the  heels,  are  now  sensitive  and  prickling. 
His  feet  feel  freezing  cold.     He  denies  alcohol  and  venereal  disease. 


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Fig.  18. — Chart  of  case  34. 


Present  Condition. — The  range  of  temperature  and  pulse  are  as 
seen  in  the  accompanying  chart.  The  patient  is  well  developed  and 
nourished,  but  looks  worn  out  and  in  much  pain.  Indeed,  he  can  scarcely 
lie  still  a  moment.  The  chest  and  abdomen  show  nothing  abnormal. 
From  the  third  to  the  eighth  dorsal  vertebra  the  backbone  is  bowed 
])()stcri()rl\-.  There  is  much  tenderness  on  pressure  over  the  se\-enlh 
cervical  spine.  There  is  no  disturbance  of  sensation  in  the  feet  or  legs, 
and  motion  is  everywhere  normal. 

The  urine  is  normal  in  amount,  to2(S  specific  gravity,  with  the  slight- 
est possible  trace  of  albumin  and  a  few  finely  granular  casts.  Xo  blood 
or  pus.     The  white  cells  number   14,800.     The  red   blocxi-cclls  show 


Io6  DIFFERENTIAL   DIAGNOSIS 

no  stippling;  :x--ray  is  negative.  The  lines  of  expression  in  both  sides 
of  the  face  are  flattened  out.  The  right  side  moves  less  than  the 
left.  The  patient  cannot  whistle,  and  protrudes  his  tongue  slightly  to 
the  right. 

The  grasp  in  both  hands  is  equal,  but  markedly  diminished. 

The  knee-jerks  are  absent,  the  superficial  reflexes  normal,  the  mind 
clear. 

Discussion. — Clearly,  we  cannot  blame  the  old  wrench  for  the  present 
trouble.  The  sciatica  also  seems  to  be  ancient  history,  though  both  of 
these  events  may  ])e  of  some  importance  as  indicating  a  locus  minoris 
resistencio'. 

In  contrast  with  all  the  types  of  lumbar  pain  previously  discussed 
this  case  stands  out,  marked  by  the  presence  of  sensory  symptoms  (numb- 
ness and  prickling)  in  the  legs.  It  is  also  notable  that  the  face  and  arms 
are  affected,  though  not  at  the  beginning  of  the  case. 

Though  the  backward  bowing  of  the  spine  brings  the  possibility 
of  Pott's  disease  to  mind,  there  is  nothing  else  in  this  region  to  support 
any  such  hypothesis,  and  neither  here  nor  in  the  cervical  region,  where 
some  tenderness  was  present,  did  .v-ray  show  any  lesions.  The  entire 
absence  of  muscular  spasm  helps  to  exclude  spinal  tuberculosis.  No 
other  disease  of  bone  or  joint  is  definitely  suggested,  and  there  is  nothing 
to  point  to  the  urinary  system  or  to  any  general  infection  as  the  source  of 
these  troubles.  The  urine  cannot  be  called  normal,  but  its  abnormalities 
are  of  a  very  vague  and  general  nature,  consistent  with  the  presence  of 
almost  any  disease  and  with  the  absence  of  all  known  disease,  so  that  in 
this  differential  diagnosis  they  may  be  disregarded. 

In  view  of  the  general  sensory  symptoms,  the  loss  of  muscular  power 
and  tone  and  the  diminished  reflexes,  multiple  neuritis  is  the  natural 
diagnosis.  Were  the  spinal  cord  involved,  one  would  expect  pupillary 
changes,  increased  reflexes,  relaxed  sphincters,  and  the  absence  of  such 
wide-spread  sensory  symptoms. 

As  to  the  cause  of  the  neuritis,  we  are  here,  as  in  so  many  other  cases, 
quite  in  the  dark.  Alcohol  and  lead  can  be  definitely  excluded.  There 
is  no  reason  to  suspect  arsenic.  The  presence  of  moderate  waves 
of  fever  and  a  continued  leukocytosis  makes  it  reasonable  to  suppose 
that  an  infectious  process  is  at  the  bottom  of  the  symptoms. 

Outcome. — The  leukocytes  continued  to  range  high,  and  the  pain 
and  the  tenderness  continued  to  be  very  troublesome.  Sterile  water  was 
given  at  times  instead  of  morphin,  and  the  patient  was  gradually  weaned 
from  his  fondness  for  the  drug. 

By  the  thirtieth  of  June  the  pains  were  less  severe  and  could  be  con- 


LUMBAR   PAIN  I07 

trolled  by  aspirin,  lo  grains,  once  or  twice  a  day,  or  by  placebos.  There 
was  moderate  muscular  wasting,  and  tenderness  along  the  nerve-trunks 
was  present. 

By  July  8th  the  grip  was  much  improved.  The  patient  was  up  and 
about  the  ward,  and  soon  went  home  to  finish  his  convalescence. 

Diagnosis. — Neuritis, 

Case  35 

A  negro  of  fifty,  with  a  negative  previous  history,  entered  the  hospital 
August  2,  1906,  complaining  that  for  three  weeks  he  had  been  suffering 
from  loss  of  appetite,  nausea,  fever,  and  weakness,  and  had  been  in  bed 
a  good  deal  of  the  time. 

Ten  days  ago  he  was  beginning  to  recover  his  strength,  but  four  days 
ago  he  suddenly  began  to  have  shooting  pain  in  the  lower  back  and  but- 
tocks, the  pains  running  down  the  backs  of  both  legs,  especially  the  left, 
and  intensified  by  motion.  He  is  fairly  comfortable  when  quiet  in  bed. 
At  the  onset  of  his  disease  he  took  large  doses  of  quinin  with  relief. 
His  bowels  now  move  every  two  or  three  days. 

On  physical  examination,  temperature,  pulse,  and  respiration 
were  found  to  be  normal,  the  cnest  and  abdomen  likewise  normal,  the 
blood  and  urine  negative.  Extension  of  the  left  leg  with  the  knee 
straight  caused  marked  pain  in  the  left  sacro-iliac  joint.  Movements  of 
the  leg  with  knee  flexed  were  not  painful.  There  was  tenderness  o\er  the 
left  sacro-iliac  joint  and  over  the  lower  dorsal  spines.  X-ray  was  nega- 
tive.    The  motions  of  the  spine  were  markedly  limited  in  all  directions. 

Discussion. — Apparently  the  symptoms  in  this  case  followed  a 
three  weeks'  febrile  illness,  the  nature  of  which  we  do  not  know.  The 
possibility  of  typhoid  and  a  post-typhoidal  spondylitis  is  naturally  sug- 
gested, but  if  typhoid  is  often  complicated  by  a  late  spondylitis,  presum- 
ably other  infections  may  have  a  similar  sequel. 

The  marked  limitation  of  s])inal  motion  and  the  tenderness  in  the 
lower  dorsal  region  make  it  necessary  to  consider  spinal  tuberculosis. 
The  negative  .r-ray,  however,  goes  far  to  exclude  this  possibility.  Only 
the  course  of  time  and  the  effects  of  treatment  can  make  us  more  certain 
on  this  |)oint.  The  same  remarks  apply  to  the  possibility  of  malignant 
disease. 

Outcome, — Dr.  Rol:»ert  B.  Osgood,  who  saw  the  case  in  consulta- 
tion, considered  it  one  of  infectious  arthritis  of  the  spine  and  the  left 
sacro-iliac  joint;  strap})ing  of  the  back,  with  enemata  and  tonics,  was 
the  treatment.  The  [)atient  was  able  to  leave  the  hospital  almost  well 
in  twelve  da}-s. 

Diagnosis. — Infectious  spondylitis. 


Io8  DIFFERENTIAL  DIAGNOSIS 

Case  36 

A  Swedish  housemaid  of  twenty-five,  with  an  excellent  family  history, 
entered  the  hospital  March  27,  1907.  She  states  that  eight  or  nine  years 
ago  she  was  in  bed  for  six  weeks  with  "catarrh  of  the  lungs,"  and  that 
since  she  was  ten  years  of  age  she  has  had  frequent  attacks  of  tonsillitis. 
Otherwise  she  has  been  well.  At  Christmas,  1906,  she  caught  cold  and 
was  weak  and  feverish.  At  this  time  her  back  became  very  sore  and 
painful  on  motion,  and  she  had  to  give  up  work  the  first  of  January. 
Since  then  she  has  not  improved  at  all,  and  has  been  in  bed  a  consider- 
able part  of  the  time.  At  entrance,  the  temperature,  pulse,  and  respira- 
tion were  normal,  the  chest  and  abdomen  negative,  the  spine  held  rigidly 
and  all  motion  painful.  There  was  no  kyphos  and  no  sacro-iliac  ten- 
derness. 

Discussion. — The  long  duration  of  the  symptoms  holds  our  attention 
at  once.  Chronic  backaches  may  be  due  to  functional  causes,  to  osteo- 
arthritis and  the  pressure  group  (Pott's  disease,  new-growths,  and  aneur- 
ysm) .  It  is  notable  that  in  this  case  a  rest  in  bed  has  not  produced  any 
marked  improvement,  neither  has  there  been  any  alarming  advance  in 
the  severity  of  the  symptoms,  such  as  would  probably  occur  with  malig- 
nant disease.  The  physical  signs  are  confined  to  the  evidence  of  a  rigid 
and  painful  spine.  Renal  lesions  and  general  infections  are  easily  ruled 
out.  Any  ordinary  lumbago  would  have  been  cured  long  before  this. 
The  spinal  rigidity  and  tenderness  make  it  ver}-  improbable  that  sacro- 
iliac disease  is  the  only  lesion  present. 

The  so-called  functional,  neurasthenic,  or  hysteric  affections  of  the 
spine  are  naturally  suggested  by  the  long  duration  of  the  symptoms,  by 
the  age  and  sex,  and  by  the  absence  of  fever,  kyphos,  and  other  obvious 
lesions.  The  outcome  of  the  case  shows  the  great  importance  of  not 
jumping  at  such  conclusions  until  every  method  of  physical  examination, 
including  the  .v-ray,  has  been  used.  This  is  especially  true  of  all  dubious 
and  chronic  cases. 

Outcome. — At  entrance,  the  diagnosis  was  "acute  osteo-arthritis 
with  a  neurasthenic  background."  An  x-ray  taken  the  first  of  April 
showed  that  the  body  of  the  second  lumbar  vertebra  was  extensi\'ely 
diseased,  and  a  knuckle  was  later  developed  in  the  lumbar  region. 
The  patient  was  put  at  once  into  a  plaster  jacket,  and  by  April  6th  was 
able  to  sit  up  with  comfort.     On  April  9th  she  left  the  hospital. 

Dr.  Osgood's  diagnosis  was  early  Pott's  disease. 

Di agnosis. — ^\''ertebral  tuberculosis. 


Fig.  19. — Area  of  pulsation  at  a  point  often  overlooked  in  jshysical  examination. 

jjlaint,  i)ain  in  the  back. 


Com- 


LUMBAR   PAIN  lOQ 

Case  37 

A  carriage  painter  of  thirty-four  entered  the  hospital  March  20, 
1907.  His  father  died  of  a  paralytic  shock;  his  family  history  was  other- 
wise excellent.  He  remembers  no  sickness  in  his  life.  Had  a  soft  sore 
eleven  years  ago,  and  a  bubo  about  the  same  time;  had  no  rash,  sore 
throat,  falling  of  hair,  or  pains  following  it,  but  was  treated  for  a  year 
after  it,  with  what  medicine  he  does  not  know. 

In  his  work  he  lifts  from  100  to  200  pounds  every  day.  He  was  per- 
fectly well  until  five  months  ago,  when  he  began  to  feel  weak.  Since 
that  time  he  has  been  losing  weight  and  has  done  no  work.  Three 
months  ago  he  strained  his  back,  and  since  then  he  has  had  a  burning 
pain  m  the  small  of  his  back  and  below  the  region  of  the  heart  on  the 
left.  This  pain  has  increased  considerably  in  the  last  three  weeks, 
and  is  now  so  severe  that  he  has  to  bend  forward  and  to  the  left  to  ease  it. 
It  is  made  worse  by  walking,  and  interferes  with  sleep.  He  has  no 
dyspnea  and  no  other  symptoms. 

Physical  examination  showed  normal  temperature  and  respiration; 
pulse  somewhat  accelerated,  keeping  most  of  the  time  between  100  and 
120.  His  pupils  are  equal  and  react  normally;  his  heart  and  lungs 
negative,  except  as  shown  in  the  diagram  (Fig.  19),  his  right  radial  pulse 
slightly  larger  than  the  left. 

There  is  resistance  and  dulness  in  the  epigastrium,  but  no  definite 
mass  made  out.  The  glands  are  considerably  enlarged  in  the  groins  and 
axilla?. 

Discussion. — As  in  the  previous  case,  the  element  of  duration  is  a 
most  important  one  in  the  diagnosis.  A  steady  pain  lasting  three  months 
is  not  likely  to  be  due  to  functional  causes  when  it  occurs  in  a  carriage 
painter  of  thirty-four.  Lead-poisoning,  suggested  by  the  occupation, 
never  produces  such  a  pain  as  this  without  other  symptoms.  The  general 
infections  and  the  renal  group  of  lesions  are  easily  excluded  by  the  physical 
examination.  This  leaves  us  with  the  diseases  which  I  have  called  the 
pressure  group  (Pott's  disease,  aneurysm,  and  neoplasm)  especially 
deserving  of  consideration.  Only  one  diagnosis  is  possible  in  tliis  case, 
provided  it  occurs  to  our  minds  at  all.  The  danger  is  that  it  will  not  be 
thought  of,  and,  tlierefore,  will  not  ])e  found  in  ])hysical  examination. 
Nothing  but  aneurysm  produces  an  impulse  and  thrill  with  dulness  and 
absent  breathing  between  the  S])inal  column  and  the  left  scapula.  Pul- 
sating ])leurisy  and  pulsating  sarcoma  do  not  i)resent  thenisehcs  at  this 
point. 

Outcome. — A'-ray  showed  a  distinct  shadow  in  the  area  of  pulsation, 


no  DIFFERENTIAL  DIAGNOSIS 

as  figured  in  the  diagram.  The  pain  felt  over  the  lower  ribs  in  front 
seemed  to  be  explained  by  pressure  of  aneurysm  on  the  intercostal  nerve. 

There  is  now  no  pain  in  the  region  of  the  tumor.  The  patient  was 
given  iodid  of  potash.  15  to  30  grains,  four  times  a  day;  nitroglycerin, 
T^TT  grain,  every  three  hours;  when  needed  for  pain  an  occasional 
dose  of  morphin,  |  grain. 

The  patient  left  the  hospital  slightly  relieved  on  June  4th. 

Diagnosis. — Aortic  aneurysm. 

Case  38 

A  laborer  of  twenty-two  entered  the  hospital  July  4,  1906,  with  a 
negative  family  history.  All  last  winter,  he  says,  he  suffered  from 
"rheumatism  around  the  heart";  otherwise  his  past  history  and  habits 
are  good. 

For  the  past  two  weeks  he  has  been  ailing,  especially  on  account  of 
pain  in  the  abdomen,  the  back,  the  neck,  or  the  head,  every  day.  The 
pain  in  the  back  has  prevented  any  continuous  sleep  for  the  last  five 
nights,  but  he  also  aches  all  over,  although  he  was  able  to  work  until 
two  days  ago.  For  the  past  week  he  has  had  a  bad  taste  in  his  mouth 
in  the  morning.  He  says  a  number  of  his  friends  have  the  same  trouble, 
and  call  it  the  "grip."  His  appetite  is  poor,  and  he  has  nausea  after 
eating.  The  bowels  are  regular;  there  are  no  other  symptoms.  A  soft, 
systolic  murmur  is  heard  all  over  the  precordia,  loudest  in  the  pulmonary 
area.  The  pulses  are  of  low  tension  and  dicrotic.  The  chest  and  abdo- 
men are  negative.  On  the  forearms  are  a  number  of  sharply  defined 
macules  and  papules,  which  decolorize  on  pressure  (mosquito  bites?). 
In  the  left  hypochondrium  is  a  group  of  rose-colored  macules,  five  in 
number. 

During  the  first  three  days  of  his  stay  in  the  hospital  he  had  fever, 
ranging  from  100°  to  103°  F.,  accompanied  by  considerable  pain  in  his 
back. 

Leukocytes  were  5900;  Widal  reaction — persistently  negative.  Xo 
malarial  organisms  were  found  in  the  blood.  The  urine  was  negative. 
His  abdomen  was  always  rigid,  and  his  bowels  difficult  to  move.  On 
the  twenty-first  of  July,  after  four  days  of  normal  temperature,  his  Ijack 
still  showed  limitation  of  motions  in  all  directions,  with  consideral)le 
tenderness  on  his  shins.  A  diagnosis  of  lumbago  was  made  this  day 
by  Dr.  Joel  E.  Goldthwait.  Under  criss-cross  strapping  his  pain  was 
almost  gone  by  the  twenty-fifth.  His  lips  were  cyanotic  throughout 
his  stay  in  the  hosi)ital;  his  appetite,  enormous. 

His  treatment  consisted  of  salicylates  and  aspirin  for  the  pain;  also 


LUMBAR   PAIN  III 

the  acetate  and  the  iodid  of  potash,  an  occasional  dose  of  morphin,  and 
laxatives.     At  entrance  he  was  treated  as  for  typhoid. 

Discussion. — The  diagnosis  of  lumbago  is  very  plausible  in  this 
case,  owing  to  the  fact  that  the  patient  has  general  limitation  of  the 
lumbar  motions,  and  has  previously  suffered  from  stiff  neck  and  other 
apparently  muscular  pains.  But  there  are  other  features  about  the  case 
which  make  it  seem  more  like  a  post-febrile  spondylitis  of  the  type  most 
often  seen  after  typhoid.  Lumbago  does  not  produce  a  fever  like  that 
here  described,  and  there  are  many  other  facts  pointing  to  the  existence 
of  a  general  infection.  The  rapid  recovery  under  a  simple  strapping 
treatment  does  not  necessarily  prove  that  the  diagnosis  is  lumbago,  but 
does  tend  to  exclude  all  other  possibilities,  except  the  two  above  men- 
tioned.    The  cyanosis  and  the  enormous  appetite  are  not  explained. 

Diagnosis. — ^Lumbago  (?)     Infectious  spondylitis  (?) 

Case  39 

An  ice-man  of  twenty-five  entered  the  hospital  April  lo,  1906.  His 
family  history  was  negative,  his  past  history  good.  He  had  urethritis 
six  months  before.  He  has  taken  five  or  six  glasses  of  beer  a  day,  and 
one  or  tvvo  glasses  of  whisky  a  week,  as  a  rule,  but  has  seldom  been  drunk. 

Except  for  the  urethritis,  he  was  well  until  two  weeks  ago,  when  he 
began  to  have  a  dull,  aching  pain  in  the  right  side  of  his  back  and  flank, 
not  severe  enough  to  make  him  give  up  work  nor  to  keep  him  awake. 
After  a  couple  of  days  this  pain  disappeared,  but  returned  five  days  ago. 
This  time  it  extended  into  the  right  leg,  but  not  into  the  groin  or  testes. 
The  painful  area  is  tender,  and  the  pain  is  constant.  He  has  noticed 
no  change  in  his  urine;  he  thinks,  however,  that  he  passes  more  urine  in 
the  night  than  in  the  day.  He  has  some  shortness  of  breath  and  pal- 
])itation  on  exertion. 

He  had  no  temperature  above  99.5°  F.  during  his  stay  of  ten  days  in 
the  hospital.  The  abdomen  was  held  firmly  al)o\e  the  navel,  was  e\ery- 
where  tympanitic,  and  in  the  right  u])])er  f|uadrant  was  tender.  At  this 
])oint  a  mass  tlie  si/c  of  the  fist  was  felt,  mcninii;  with  respiration, 
ap])arently  l()l)ulated,  and  coming  down  a  hand's  breadth  l)el()w  the  ribs 
on  full  ins[)iration.  It  was  easily  felt  bimanually,  and  could  be  partially 
re])Iaced  behind  the  ribs. 

The  urine  was  between  60  and  80  ounces  in  twenty- four  hours,  and 
contiiined  a  very  slight  trace  of  albumin,  in  the  sediment  were  many 
intracellular  di])lococci,  decolorizing  bv  (Iram's  stain.  Twenty  niininis 
of  the  sediment  of  urine  was  inoculated  into  a  guinea -])i^.  'ilie  animal 
was  killed  two  months  later,  and  showed  no  t'\  idenee  i^i  tiibereiilosis. 


112  DIFFERENTIAL   DIAGNOSIS 

On  the  twentieth  of  April  jc-ray  showed  a  definite  shadow  in  the  region 
of  the  right  kidney.  Dr.  Davis  catheterized  the  right  ureter  and  ob- 
tained pus  containing  gonococci. 

Discussion. — Everything  points  to  the  kidney  as  the  source  of  this 
patient's  troubles.  Our  suspicions  in  that  direction  are  promptly  con- 
firmed as  the  result  of  cystoscopy,  x-Ta.y  examination,  and  animal 
inoculation,  a  group  of  procedures  demanded  in  almost  every  case  of 
chronic  renal  pyuria. 

Since  "surgical  kidney"  is  excluded  by  the  cystoscopic  examination, 
and  tuberculosis  by  the  results  of  animal  inoculation,  the  only  important 
possibility  left  is  renal  stone,  a  supposition  strongly  supported  by  the 
rc-ray  evidence. 

Outcome. — The  patient  was  transferred  to  the  surgical  ward  and 
operated  upon  on  May  2d.  A  stone  was  removed.  The  patient's 
convalescence  took  place  without  any  incident  and  he  was  discharged 
May  26th. 

He  was  readmitted  December  5,  1907.  After  leaving  the  hospital 
he  was  well  and  strong,  and  worked  hard  until  three  weeks  ago,  when  he 
began  to  pass  blood  and  pus  in  his  urine  and  suffered  pain  in  the  right 
lumbar  region,  similar  to  that  which  he  had  previously  had.  He  now 
suffers  from  two  sorts  of  pain :  (a)  A  dull  ache  in  the  right  side,  present 
most  of  the  time;  and  (b)  a  stinging  pain  occurring  only  after  micturition, 
starting  from  the  urinary  meatus  and  running  up  into  the  right  side. 
The  urine  continued  bloody  for  the  first  week  of  this  attack,  the  last 
two  Of  three  spoonfuls  of  each  discharge  being  bright  blood  with  threads 
of  yellow  pus.  Of  late,  no  blood  has  been  visible.  He  has  lost  appetite 
and  has  been  very  thirsty,  although  he  has  not  been  conscious  of  any 
fever.  He  has  lost  about  10  pounds  in  weight.  The  patient  entered 
the  hospital  with  a  temperature  of  102°  F.,  pulse  120.  After  two  days 
the  temperature  subsided  to  normal.  His  leukocytes  were  10,000  at 
entrance.  The  abdomen  was  altogether  normal,  but  in  the  right  flank 
there  was  a  visible  prominence  and  a  palpable,  tender,  dull,  rounded, 
lobulated  mass,  apparently  retreating  under  the  ribs  on  pressure. 

The  urine,  as  at  the  previous  entry,  was  persistently  of  low  gravity, 
ranging  from  ion  to  1014,  and  rather  large  in  amount — from  50  to  70 
ounces  a  day.  The  sediment  was  composed  almost  entirely  of  pus  in 
moderate  amounts.  The  pus  persisted  in  his  urine,  and  the  patient  con- 
tinued to  have  considerable  pain  in  the  right  flank,  A'-ray  showed  only 
doubtful  shadows  of  a  possible  stone. 

Operation,  December  24th,  showed  no  stone,  but  many  pockets  of 
pus  scattered  throughout  the  kidney,  with  smaller  foci  of  round-cell 


LUMBAR    PAIN 


113 


infiltration  between  them.  The  kidney  was  enlarged,  and  at  one  end 
was  fibrous.  Its  pelvis  was  normal.  The  patient  did  well  after  nephrec- 
tomy. 

Diagnosis. — Renal  stone;  multiple  abscesses. 

Case  40 

A  housewife  of  fifty-one  entered  the  hospital  August  11,  1906,  for 
the  third  time.  At  her  first  entry,  in  June,  1899,  a  diagnosis  of  gall- 
stones had  been  made;  at  the  next  entry,  June,  1901,  neurasthenia  was 
the  diagnosis.  Her  attacks  of  illness  between  February,  1899,  and 
December,  1901,  were  very  frequent  and  of  a  similar  character.  There 
was  a  sudden  occurrence  of  pain,  severe  and  cramp-like,  doubling  her  up. 
It  always  started  in  the  right  side  of  the  back,  thence  radiating  to  the 
right  h}'pochondrium,  but  never  to  the  right  shoulder.  It  would  last 
from  two  hours  to  two  days,  and  was  relieved  occasionally  by  household 
remedies,  but  always  by  morphin.  After  relief  there  would  be  no 
recurrence  for  weeks  or  months.  The  pain  was  associated  with  \omit- 
ing,  but  showed  no  special  tendency  to  occur  at  night.  The  urine  and 
feces  were  normal,  and  there  was  no  fever  with  the  attacks.  Twice 
she  entered  the  hospital  for  these  attacks,  ])ut  has  always  been  free  from 
pain  while  here.  For  the  past  two  and  a  half  weeks  she  has  had  an  attack 
every  day,  sometimes  in  the  afternoon,  sometimes  at  night.  Morphin 
has  been  injected  several  times,  and  she  has  had  mor]:)hin  pills  on  hand. 
Her  bowels  are  moved  daily,  but  she  has  had  no  appetite. 

Her  physical  examination,  including  blood  and  urine,  temperature, 
pulse,  and  respiration,  was  wholly  negative.  On  the  thirteenth,  at  3  a.  m., 
she  began  to  have  severe  pain.  A  rounded  tumor  was  easily  felt  below 
the  ribs,  in  the  region  of  the  gall-bladder,  moving  with  respiration,  and 
easily  mapped  out  by  percussion. 

Discussion. — Colicky  pain  in  the  right  lumbar  region  naturally 
suggests  renal  stone.  In  the  absence  of  any  urinary  changes,  however, 
an  .r-ray  would  be  necessary  to  confirm  the  diagnosis.  The  account  of 
the  ])ain  does  not  sound  like  that  of  lumbago,  which  is  not  }iromi)tly 
driven  away  by  morphin,  and  is  rarely  so  severe  as  to  call  for  its  use. 

Another  cause  for  the  pain  is  suggested  l)y  the  rounded  tumor  in  the 
right  hypochondrium.  This  tumor  might  be  connected  with  the  stom- 
ach or  intestine,  but  the  absence  of  gastric  or  intestinal  symptoms  l)c- 
twecn  the  attacks  of  colic  makes  this  unlikely.  It  seems  more  ])robal)le 
that  the  tumor  is  due  to  distention  of  the  gall-])la(kler.  the  absence  of 
jaundice  being  due  to  the  fact  that  the  common  duct  is  patent. 

It  is  well  to  say  a  word  in  condenmation  of  the  previous  diagnosis 


II_j.  DIFFERENTIAL  DIAGNOSIS 

of  neurasthenia,  based,  apparently,  on  the  fact  that  the  patient  happened 
to  be  in  the  hospital  during  an  interval  between  her  severe  attacks. 
Such  a  diagnosis,  based  wholly  on  negative  findings,  is  always  unjustified; 
for  the  patient  it  is  often  adding  insult  to  injury.  It  is  far  better  to  make 
no  diagnosis  at  all  and  watch  for  a  recurrence  of  the  previous  symptoms. 

Outcome. — X-vdij  of  the  renal  region  was  negative.  On  the  fifteenth 
the  abdomen  was  opened,  and  a  number  of  gall-stones  were  found  in  the 
gall-bladder. 

Diagnosis. — Gall-stones. 

Case  41 

A  longshoreman  of  forty-four  with  a  good  family  history  entered  the 
hospital  March  7,  1907. 

He  had  used  a  quart  of  ale  daily  until  five  weeks  ago.  In  1883  he 
had  malaria  in  India.  In  1890  he  had  blood-poisoning  of  the  arm,  and 
was  in  the  Royal  Infirmary,  Liverpool,  twenty-five  days. 

Two  years  ago  he  had  ''pleurisy,"  and  half  a  gallon  of  fluid  was 
taken  from  his  left  chest. 

March  28,  1906,  he  had  some  operation  done  on  his  right  testis,  just 
for  what  cause  he  does  not  know.  Since  then  he  has  been  well  until 
five  weeks  ago.  He  entered  the  hospital  March  7,  1907,  complaining  of 
constant  pain  across  the  small  of  his  back.  It  has  been  severe  for  the 
past  two  weeks,  so  as  to  prevent  work  or  sleep.  For  a  week  he  has  had 
frequent  cramps  in  his  calves,  and  lately  has  been  short  of  breath.  He 
has  lost  14  pounds  in  the  five  weeks. 

Physical  examination  of  the  abdomen  showed  in  the  right  hypochon- 
drium  and  epigastrium  two  smooth,  rounded  masses,  palpable  biman- 
ually,  descending  with  respiration.  (See  Figs.  20  and  21.)  On  inflation  of 
the  stomach  the  masses  appeared  to  be  behind  it.  Physical  examination 
was  otherwise  negati\-e,  except  that  the  urine  was  of  low  gravity — 1007 — 
ranged  in  amount  from  70  to  120  ounces  during  the  week  of  his  stay 
in  the  hospital,  and  contained  in  its  sediment  a  few  hyaline  and  fine 
granular  casts.     X-ray  of  the  spine  was  negative. 

The  gastric  contents  contained  no  hydrochloric  acid  after  a  test- 
meal.  The  size  of  the  stomach  -was  normal,  and  there  were  no  organic 
acids  or  fasting  contents. 

Discussion.— The  occupation  is  one  of  those  often  associated  with 
lumbago  or  spinal  osteo-arthritis,  but  for  simple  lumbago  the  pain 
has  been  rather  too  steady  and  prolonged.  The  question  of  osteo- 
arthritis will  be  referred  to  later. 

The  history  of  pleurisy,  together  with  a  severe  and  long-standing 


Fig.  20. — <  )ullinc  of  masses  felt  March  8th,  Case  41.      (Sec  alsf)  Fig.  21.) 


uinl'ar    pain.     (Sec   also 


LUMBAR   PAIN 


"5 


spinal  pain,  often  points  to  a  spinal  tuberculosis.  It  is  quite  possible, 
also,  that  the  previous  operation  may  have  been  for  tuberculous  epi- 
didymitis. Against  this  diagnosis,  however,  is  the  absence  of  fever  and 
muscular  spasm,  as  well  as  the  negative  jc-ray  examination. 

The  two  latter  facts  are  also  against  the  diagnosis  of  osteo-arthritis, 
though  this  cannot  possibly  be  excluded. 

We  naturally  desire  to  connect  all  the  symptoms  and  signs  in  the  case 
into  a  mutually  explaining  group,  and  this  brings  us  to  the  consideration 
of  the  abdominal  tumors.  Cystic  kidney  (congenital)  would  produce 
such  a  tumor  and  such  a  urine,  but  as  it  is  in^'ariably  bilateral,  we  should 
expect  to  get  some  evidence  of  a  tumor  in  the  left  hypochondrium. 
Further,  cystic  kidneys  never  cause  pain  in  the  back  of  anything  like  the 
severity  here  complained  of. 

Hydronephrosis  would  explain  the  tumor,  and  possibly  the  urine,  but 
would  not  account  for  the  pain. 

Can  the  tumor  be  in  the  stomach,  possiljly  with  spinal  or  glandular 
metastases  to  account  for  the  pain?  This  is  suggested  by  the  absence  of 
hydrochloric  acid  in  the  gastric  contents,  but  it  must  be  remembered  that 
a  similar  lack  of  hydrochloric  acid  has  been  frequently  demonstrated  in 
association  with  malignant  tumors  of  any  organ,  e.  g.,  cancer  of  the 
breast,  as  well  as  in  a  variety  of  debilitated  conditions.  Since  no  gastric 
sym])toms  are  complained  of,  and  there  are  no  changes  in  the  size  or 
motility  of  the  stomach,  a  gastric  tumor  seems  unlikely. 

Retroj)eritoneal  growths  certainly  deserve  consideration.  The 
previous  tumor  of  the  testis  may  well  have  been  sarcoma,  and  if  so,  a 
metastasis  in  the  retroperitoneal  lymph-glands  would  be  ^"ery  likely. 
Further  than  this  one  cannot  go  without  exploratory  operation. 

Outcome.- — The  abdomen  was  opened  on  March  15th,  and  a  retro- 
peritoneal mass  the  size  of  a  grape-fruit  was  found  ])ehind  the  ])ylorus. 
It  was  afterward  learned  that  the  tumor  of  the  testis  was  sarcoma. 

Diagnosis. — Retroperitoneal  sarcoma. 

Case  42 

A  medical  student  of  twenty-three  entered  the  hospital  July  18,  1907. 

He  had  tyj)hoid  fever  in  the  Alassachusetts  Hos])ital  in  August  and 
Septcml)er,  1906.  After  that  lie  went  back  to  college  for  the  seccMid 
half-year  in  February,  1907,  taking  his  work  easily,  but  finding  it  hard 
to  concentrate  his  attention,  having  a  good  deal  of  pain  in  the  [(^rrhcad 
after  studying,  and  needing  to  lie  down  every  afternoon.  Ol^  March 
ist  he  had  an  attack  of  severe  ])ain  in  the  small  of  his  Inick;  this  lasted 
live  days,  with  much  stiffness.     Four  weeks  ago  he  had  am)t]KT  attack, 


ii6 


DIFFERENTIAL    DIAGNOSIS 


following  exposure  to  cold  and  wet,  lasting  four  days.  For  the  past 
three  weeks  he  has  been  in  bed  with  the  same  trouble.  Ten  days  ago 
he  woke  up  in  the  night,  doubled  up  with  pain,  and  had  to  have  morphin 
to  relieve  it. 

On  physical  examination  the  knee-jerks  were  found  to  be  exaggerated. 
Kernig's  sign  was  marked,  and  ankle  clonus  present. 

Temperature  at  entrance  was  102°  F.,  pulse,  120,  but  after  forty- 
eight  hours  both  pulse  and  temperature  were  normal. 

The  white  count  was  3200;  urine  was  negative. 

The  spine  was  held  rigidly  in  extreme  lordosis,  with  well-marked 
spasm  of  .the  erector  spinae  group.     The  patient  was  unable  to  stand  or 


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Fig.  22. — Chart  of  case  42. 


to  sit  erect.  The  hip  motions  were  free  and  normal,  except  that  hyper- 
extension  of  the  right  hip  is  painful.  There  is  slight  tenderness  on  pres- 
sure over  the  right  sacro-iliac  joint. 

Discussion. — A  rigid,  tender  spine  following  typhoid  fever  and 
associated  with  some  neurotic  sjinptoms  is  almost  the  typical  picture  of 
post-typhoidal  spinal  arthritis.  The  chief  objection  to,  such  a  diag- 
nosis in  this  case  is  the  long  duration  of  the  interval  between  the  typhoid 
fever  and  the  present  symptoms.  Almost  all  cases  of  "typhoid  spine" 
come  on  within  three  months,  while  in  this  case  the  interval  is  almost 
six  months.  This,  however,  is  by  no  means  convincing  evidence  against 
the  diagnosis. 


LUMBAR   PAIN 


117 


In  the  earlier  editions  of  Osier's  text-book  this  disease  was  described 
as  a  neurosis  without  anatomic  basis.  The  reason  for  this  belief  is  sug- 
gested in  the  present  case,  as  in  the  majority  of  all  cases.  Mental  symp- 
toms, of  the  type  usually  referred  to  as  neurotic  or  neurasthenic,  consti- 
tute one  of  the  varieties  of  post-typhoidal  psychosis,  and  may  be  obstinate 
and  long  continued.  Various  types  of  insanity  are  also  met  with  as 
sequelae  of  typhoid,  though  nearly  all  of  them  recover.  It  is  easy  to  see 
how  mental  depression,  associated  with  muscular  relaxation,  might 
accent  and  aggravate  the  symptoms  of  an  otherwise  latent  spondylitis. 
That  spondylitis  may  be  latent  is  proved  by  the  occasional  finding  of 
rigid  spines  in  patients  who  have  never  experienced  any  previous  pain, 
and  in  whom  x-ray  demonstrates  osteo-arthritic  lesions. 

Outcome. — Dr.  R.  B.  Osgood  saw  the  case  in  consultation,  and  con- 
sidered it  a  typhoidal  arthritis  of  the  lower  spine  and  sacro-iliac  joints. 

On  the  twenty-third  a  plaster  jacket  was  applied,  with  complete 
relief  to  the  pain  in  the  back.  The  patient  had  a  good  deal  of  vomiting, 
and  for  some  days  took  nothing  but  cracked  ice  by  mouth.  At  this  time 
the  urine  showed  a  trace  of  albumin,  with  hyaline,  granular,  and  epithelial 
casts  in  small  numbers. 

The  Widal  reaction  was  positive. 

The  second  week  of  his  stay  in  the  hospital  he  had  a  rise  in  tem- 
perature (see  accompanying  chart)  lasting  five  days.  The  patient  was 
very  hysterical,  and  a  false  chart  hung  at  the  head  of  his  bed  had  a 
salutary  effect.  After  the  application  of  his  plaster  jacket  he  had  no 
pain.  On  the  eighth  of  August  he  was  able  to  sit  up  in  a  chair.  On  the 
fourteenth  he  was  discharged,  much  relieved.  On  the  twenty-sixth  of 
August  he  reported  that  he  had  been  walking  as  much  as  twice  a  day 
without  pain.  He  was  still  hypochondriacal  and  introspective,  but  was 
otherwise  well. 

Diagnosis. — Typhoidal  spondylitis. 

Case  43 

A  Jewish  housemaid  of  t\\-enty,  with  a  good  family  history  and  pa?t 
history,  entered  the  hos])ital  September  2,  1907.  She  said  that/*:?;'  tico 
years  she  had  had  a  steady  and  rather  severe  pain  in  the  small  of  the  haeh. 
At  the  beginning  of  this  period  slie  was  in  l)e(l  for  three  months,  after 
which  she  was  able  to  work,  although  her  back  was  stilT  and  her  trunk 
l)cnt  toward  the  riglit.  Last  winter  she  had  for  scwral  \vceks  a  jtainful 
cough,  without  expcct()ration;  she  had  no  fever  at  an}"  time.  Ahliougli 
in  constant  pain,  she  lias  worked  until  three  days  ago. 

There    was   no    fe\er.     l-'xamination    of    tlie    chest    and    ab(l<Mnen, 


Il8  DIFFERENTIAL  DIAGNOSIS 

blood,  and  urine  was  negative.  The  left  knee-jerk  was  considerably 
livelier  than  the  right.     The  spinal  muscles  were  rigid. 

Discussion. — The  most  important  fact  about  this  particular  case  of 
lumbar  pain  is  that  it  has  lasted  far  longer  than  any  other  hitherto 
described.  Such  prolonged  suffering  suggests  either  some  member  of 
the  "pressure  group"  (aneurysm,  tuberculosis,  or  neoplasm),  or  a  func- 
tional neurosis;  no  general  infection,  no  form  of  renal  disease,  and  none 
of  the  orthopedic  group  of  diseases  would  last  so  steadily  and  so  long. 

A  functional  neurosis  is  not  likely  in  a  girl  who  keeps  steadily  at 
work,  although  in  constant  pain.  The  difference  in  the  knee-jerks  is 
also  decidedly  against  this  diagnosis.  The  patient  is  rather  young  either 
for  neoplasm  or  for  aneurysm.  The  muscular  rigidity,  the  long  duration 
of  the  pain,  and  the  history  of  a  previous  cough  support  the  suspicion 
of  tuberculosis. 

Outcome. — Just  below  the  level  of  the  twelfth  rib  a  knuckle  the  size 
of  a  small  apple  was  later  made  out;  it  was  very  tender  and  hard,  not 
red  or  hot.  The  patient  was  then  in  exquisite  pain,  but  on  the  applica- 
tion of  a  plaster  jacket  was  greatly  relieved. 

Diagnosis. — Spinal  tuberculosis. 

Case  44 

A  married  woman  of  fifty  entered  the  hospital  October  lo,  1907. 
Her  family  history  was  good.  She  passed  the  menopause  one  year  ago. 
Her  menstruation  has  always  been  irregular,  profuse,  and  painful.  She 
has  had  no  children  and  no  miscarriages.  In  childhood  she  had  rheuma- 
tism, typhoid  fever,  and  abscesses  on  the  forearm.  For  the  past  fifteen 
years  she  has  had  stomach  trouble,  symptoms  consisting  of  lack  of  ap- 
petite, distress  after  eating,  and  constipation.  For  the  past  two  months 
she  has  had  frequent  severe  pains  in  the  back,  chest,  neck,  and  legs;  also 
occipital  headache,  "pins  and  needles"  in  the  legs,  noises  in  the  head, 
buzzing  in  the  ears,  palpitation  of  the  heart,  insomnia,  and  great  ner- 
vousness. Examination  of  the  throat  showed  a  linear  aperture  three- 
quarter  inch  long  in  the  soft  palate  in  the  median  line. 

There  was  anterior  bowing  of  both  shin  bones,  with  roughening  of 
their  front  surfaces,  and  three  large  white  scars;  also  two  or  three  deep 
scars  on  the  extensor  surface  of  the  left  forearm.  Spinal  motions  were 
limited  in  all  directions,  but  the  pain  was  greatly  relieved  1)y  strapping 
and  rest.  Dr.  E,  G.  Brackett  examined  the  spine  and  considered  the 
trouble  an  acute  infectious  ostco-arthritis. 

Discussion. — In  any  patient  who  has  such  a  multitude  and  variety 
of  symptoms  as  this  we  naturally  suspect  a  psychoneurosis,  especially 


LUMBAR   PAIN 


119 


as  the  menopause  has  recently  occurred.  There  are  a  number  of  data, 
however,  brought  out  by  the  physical  examination,  which  point  in 
another  direction.  The  hole  in  the  soft  palate  is  almost  pathognomonic 
of  old  syphilis,  especially  when  taken  in  connection  with  the  scars  on 
the  extremities  and  the  roughening  and  the  prominence  of  the  shin 
bone. 

There  is  no  reasonable  doubt,  then,  that  this  patient  has  suffered 
from  S}'philitic  infection.  The  question  remains  whether  this  can  ex- 
plain her  present  complaints.  That  syphilis  may  attack  the  spinal 
column  has  been  satisfactorily  demonstrated  by  :x:-ray  evidence.  At  the 
same  time,  it  is  quite  possible  that  her  present  troubles  may  be  due  to  an 
acute  infectious  process  of  some  other  origin,  or  to  purely  functional 
derangements.  Only  by  further  observation  and  by  noting  the  effects 
of  treatment  can  the  diagnosis  be  definitely  established. 

Outcome. — -The  patient  was  also  given  sodium  salicylate,  10  grains 
every  hour,  until  toxic.  Citrate  of  potash,  45  grains  four  times  a  day, 
until  the  urine  became  alkaline.  Later,  iodid  of  potash,  15  grains 
three  times  a  day,  increasing  10  grains  daily,  when  the  other  drugs 
were  omitted. 

Diagnosis. — Old  syphilis;  acute  spondylitis. 

Case  45 

An  Italian  fruit-dealer  of  twenty-three  is  in  the  habit  of  carrying 
heavy  loads,  and  thinks  he  has  strained  his  back.  He  has  never  been 
sick  otherwise,  and  has  good  habits  and  a  good  family  history.  He  was 
first  seen  August  16,  1907.  For  five  years  he  has  had  attacks  of  pain  in 
the  right  side  of  his  back  almost  every  day.  The  pain  is  sharp,  and  he 
says  it  feels  as  if  something  was  "rolling  over"  in  his  back.  Six  days 
ago  the  pain  lasted  all  day.  It  never  radiates  to  any  other  point,  and 
has  not  often  kept  him  awake.     It  does  not  hurt  him  to  stoop. 

Physical  examination  was  entirely  negative,  except  for  the  presence  of 
numerous  musical  rales,  with  slightly  prolonged  expiration  throughout 
both  chests. 

Discussion. — Muscular  strain  or  luml^ago  is  our  first  thought  in  this 
case;  it  was  the  patient's  own  explanation  of  his  troubles.  The  long 
duration  and  paroxysmal  occurrence  of  the  symptom,  however,  and  its 
independence  of  stooping,  make  this  idea  impossil^le.  Any  lumbar  pain 
that  lasts  so  long  suggests  one  of  the  pressure  group  of  causes,  but 
physical  examination  does  not  bear  this  out.  The  pain  should  be  steadier 
and  less  intermittent  were  it  due  to  j^ressure.  Tlie  same  considerations, 
together  with  the  absence  of  radiation  or  niglit  attiicks,  tend  to  exclude 


I20  DIFFERENTIAL   DIAGNOSIS 

osteo-arthritis  and  sacro-iliac  disease.  The  absence  of  local  tenderness 
and  urinary  changes  militates  against  the  idea  of  renal  disease. 

Vertebral  tuberculosis  was  suggested  by  the  prominence  of  certain 
vertebral  spines,  and  by  the  doubtful  phenomena  in  the  lungs.  The 
absence  of  any  muscular  spasm  or  tenderness  makes  this  more  unlikely, 
but  :v-ray  should  be  taken  in  confirmation.  On  the  whole,  from  the 
paroxysmal  nature  of  the  attack,  some  renal  lesion  seems  the  most 
likely. 

Outcome. — Aug.  19th  there  was  no  muscular  spasm  or  tenderness 
about  the  spine  or  sacro-iliac  joints,  but  he  could  not  bend  to  the  left  as 
well  as  to  the  right.  The  vertebral  spines  from  the  eighth  to  the  twelfth 
dorsal  were  slightly  more  prominent  than  their  neighbors.  There  were 
slight  prolongation  of  expiration  and  a  shade  of  dulness  at  the  right  apex. 
Numerous  musical  rkles  were  scattered  through  both  chests.  There  was 
no  fever.     Blood  and  urine  were  still  normal. 

Physical  examination  was  otherwise  negative.  The  patient  was 
free  from  pain  and  said  he  felt  perfectly  well.  X-ray  showed  a  stone 
in  the  right  kidney.  Operation  on  the  twenty-fourth  verified  this 
diagnosis. 

Diagnosis. — Renal  stone. 

Case  46 

A  housewife  of  twenty-three  was  first  seen  December  29,  1907. 
For  three  months  she  has  been  having  pain  in  the  left  side  of  her  back, 
worse  at  the  menstrual  period,  and  accompanied  by  constipation  and 
general  weakness.  She  has  kept  at  work  until  two  days  ago.  Family 
history,  past  history,  and  habits  are  good.  The  physical  examination 
is  negative  in  all  respects. 

Discussion. — The  chronicity  and  steadiness  of  the  pain  are  like 
those  often  seen  in  spinal  tuberculosis,  and  this  disease  can  only  be 
positively  excluded  by  x-ray  examination  and  by  the  course  of  the  case, 
though  it  is  made  unlikely  by  the  absence  of  muscular  spasm  of  fever 
and  of  local  tenderness  or  prominence. 

Kidney  lesions  cause  unilateral  pain  like  that  here  described,  but 
there  is  no  further  evidence  to  support  any  such  hypothesis. 

The  orthopedic  group  of  lesions  is  excluded  by  the  mobility  of  the 
spine  and  the  absence  of  local  tenderness. 

Since  there  is  no  fever,  we  have  no  good  reason  to  suspect  any  infec- 
tious disease. 

If  the  a*-ray  proves  negative,  the  case  must  be  treated  as  one  of  func- 
tional pain,  while  we  await  further  deA'elopments. 


LUMBAR   PAIN  121 

Outcome. — After  a  week's  rest  in  bed  with  German  powder  as  a 
laxative  the  patient's  symptoms  were  entirely  relieved,  and  as  the  rc-ray 
was  wholly  negative,  she  was  allowed  to  resume  work. 

Diagnosis. — Debility. 

Case  47 

A  blacksmith  of  thirty-one  was  seen  July  21,  1906.  Seven  days  ago 
he  began  suddenly  to  have  sharp  stabbing  pains  in  the  lower  part  of  both 
chests  and  on  both  sides  of  his  back,  and  was  unable  to  take  a  deep 
breath  on  account  of  the  pain.  Three  days  ago  he  gave  up  his  work. 
Two  days  ago  he  went  to  bed.  He  has  felt  feverish,  especially  at  night; 
for  the  last  two  days  has  had  general  headache  and  has  slept  poorly. 
Just  before  the  onset  of  the  present  illness  a  horse  had  thrown  him  heavily 
against  a  building.  He  had  a  negative  past  history  and  family  history 
and  good  habits. 

On  physical  examination  the  pupils  were  found  to  be  equal  and  to 
react  normally.  The  chest  showed  nothing  abnormal.  The  abdomen 
was  full  and  rather  rigid,  but  showed  nothing  else  of  interest.  The 
spleen  was  not  palpable.  Flexing  the  neck  caused  pain  in  the  back,  but 
there  was  no  rigidity  of  the  neck  muscles  and  no  Kernig  sign. 

The  white  cells  were  5200.  Stained  specimen  negative.  Widal 
reaction  and  blood  culture  negative.     The  urine  was  normal. 

The  temperature  ranged  between  102.5°  and  105.5°  ■^-  ^^^  ^^^  days, 
the  pulse  gradually  rising  from  100  to  120,  the  respiration  most  of  the 
time  ranging  between  40  and  50  to  the  minute.  The  abdomen  became 
more  distended,  and  on  the  twenty-fourth  the  patient  developed  delirium 
and  tremor.  On  the  twenty-sixth  his  neck  was  found  to  be  entirely 
rigid,  though  rotation  was  possible  without  pain. 

Discussion. — The  onset  of  the  present  symptoms  immediately 
after  an  accident  makes  it  natural  that  we  should  attempt  to  connect 
them  with  some  injury  then  sustained,  but  the  negative  \isccral  exam- 
ination and  the  presence  of  continued  fever  make  it  probable  that 
the  accident  had  nothing  to  do  with  the  case. 

I  have  known  tertian  makiria  to  begin  exactly  in  this  way,  with  sharp 
stabbing  pain  in  the  lower  part  of  both  chests,  but  in  that  case  the  char- 
acteristic course  of  the  fever,  with  remissions  on  alternate  days,  quickly 
led  me  to  examine  the  blood  and  to  demonstrate  malarial  jxirasites.  In 
the  j)rcscnt  case  the  temperature  curves  and  the  results  of  blootl  examina- 
tion enable  us  to  exclude  malaria. 

With  the  ra[)id  onset  of  thoracic  yxiin,  fever,  headaclie,  and  accflcr- 
ated  res{)iration  we  should  consider  j)neumonia,  which  may  be  j^rcscnt 


122  DIFFERENTIAL   DIAGNOSIS 

even  without  demonstrable  signs  in  the  chest  and  without  leukocytosis. 
Within  a  few  days,  however,  repeated  and  painstaking  examinations  of 
the  lungs  usually  demonstrate  some  evidence  of  solidification,  even 
when  cough  and  sputum  are  absent.  No  such  signs  developed  in  this 
case. 

Typhoid  fever  was  the  diagnosis  made  during  the  first  five  days  of 
the  patient's  illness,  and  in  the  absence  of  all  physical  signs,  with  con- 
tinued fever  and  low  white  count,  this  was  probably  as  good  a  guess  as 
we  could  expect  to  make.  With  the  appearance  of  stiffening  of  the  neck 
on  the  twenty-sixth  of  July  the  diagnosis  was  promptly  changed  to 
meningitis,  though  the  condition  known  as  meningismus  complicating 
typhoid  was  also  a  possibility;  indeed,  between  meningitis  and  menin- 
gismus— /.  e.,  between  cerebral  congestion  and  actual  exudation  of  the 
pus-formation — we  have  no  certain  way  of  distinguishing. 

Outcome. — Kernig's  sign  and  leukocytosis  appeared  next  day,  and 
the  delirium  ceased,  though  a  low  muttering  and  twitching  of  the  arms 
continued.  Lumbar  puncture  was  tried  on  the  twenty-seventh,  but 
no  fluid  was  obtained. 

Throughout,  the  patient's  behavior  was  strikingly  like  that  seen  in 
typhoid.     Death  occurred  on  the  second  of  August. 

Autopsy  showed  acute  purulent  leptomeningitis ;  septicemia  (strep- 
tococcus pyogenes) ;  hypertrophy  and  dilatation  of  heart;  septic  hyper- 
plasia of  the  spleen;  obliterated  extra  ureter  on  the  left  side;  fatty  meta- 
morphosis of  the  liver;  fibrous  cord  from  umbilicus  to  the  mesentery. 

Case  48 

An  unmarried  seamstress  of  nineteen  entered  the  hospital  January 
25,  1908.  The  girl  had  never  been  sick  until  a  few  days  ago,  when  she 
began  to  have  pain  in  the  small  oftlie  hack,  relieved  by  lying  down,  a  good 
many  headaches,  and  an  occasional  vomiting  spell.  There  was  no 
costovertebral  tenderness;  the  urine  was  negative.  The  spine  was  nor- 
mally flexible  without  pain,  and  no  tenderness  in  the  sacro-iliac  joints 
could  be  elicitated  by  any  maneuver.  Fever  was  absent.  Tlie  cata- 
menia  had  been  absent  for  three  months. 

Vaginal  examination  showed  a  mass  the  size  of  a  horse  chestnut, 
reddened  and  eroded,  protruding  slightly  from  the  vulva,  but  reducible. 
In  the  posterior  culdesac  was  a  mass  the  size  of  a  large  apple,  not  at  all 
movable,  apparently  in  the  back  of  the  uterus.  There  was  milk  in  the 
breasts,  and  the  areolae  were  darkly  pigmented.  Under  light  ether 
anesthesia  it  was  easily  possible  to  free  the  fundus  from  the  sacrum 
and  to  put  the  whole  organ  into  normal  position.     Examination  then 


Fig.  23. — Signs  as  recorded  in  Case  49.      Lumbar  pain  is  the  chief  symptom.      (See  also 

Fig.  24.) 


Fig.  24. — Results  of   ])hysical   examination   of   the   chest  in  a  case  of  lumbar  pain.      (See 

also  Fig.  23.) 


LUMBAR   PAIN 


123 


showed  a  normal  uterus  enlarged  about  the  size  of  a  three  and  a  half 
months'  pregnancy  with  a  very  soft,  patulous  cervix. 

Discussion. — In  the  absence  of  all  the  causes  of  lumbar  pain  hereto- 
fore discussed,  and  in  view  of  the  amenorrhea,  a  pelvic  examination  was 
obviously  indicated.  The  only  remaining  question  is  whether  the 
symptoms  are  likely  to  have  been  due  to  the  condition  of  the  uterus. 
The  anatomic  position  of  the  displaced  and  enlarged  organ  as  here 
described  seems  to  me  to  put  it  in  a  different  category  from  any  of  the 
minor  pelvic  disorders  to  which  I  have  previously  referred  as  unlikely 
of  themselves  to  cause  lumbar  pain.  The  question  seems  to  me  sohed 
in  all  reasonable  probability  by  the — 

Outcome. — The  patient  was  entirely  relieved  by  these  procedures. 

Diagnosis. — Prolapsed,  retroverted,  incarcerated,  pregnant  uterus. 

Case  49 

A  Russian  housewife,  twenty-eight  years  old,  entered  the  hospital 
December  10,  1908,  complaining  of  sharp  pain  in  the  back  and  on  both 
sides  of  the  chest  below^  the  ribs,  which  has  lasted  a  week.  She  has 
also  had  a  cough  for  the  past  three  weeks.  She  is  eight  months'  preg- 
nant. At  entrance  her  temperature  is  101°  F.;  pulse,  125;  respiration, 
32.  She  is  slightly  cyanotic.  The  heart's  apex  is  in  the  fifth  interspace, 
anterior  axillary  line,  14  cm.  to  the  left  of  midsternum.  A  harsh  systolic 
murmur  is  heard  at  the  apex  and  in  the  axilla.  The  pulmonic  second 
sound  is  accentuated.  The  superficial  veins  over  the  chest  are  very 
prominent.  Near  the  junction  of  the  second  rib  with  the  sternum  on 
each  side  are  seen  tortuous  arteries  which  pulsate  visibly.  In  the  lower 
left  axilla  there  is  flatness,  absence  of  breath-sounds,  and  fine  crackHng 
sounds.  (See  Fig.  24.)  The  abdomen  is  distended  as  by  a  pregnant 
uterus.  A  fetal  heart  is  heard  in  the  left  lower  quadrant;  rate,  148. 
The  pain  in  the  back  is  intermittent. 

Discussion. — Only  one  question  need  be  seriously  considered  in 
this  case.  Is  the  pain  due  to  an  infectious  disease  or  to  the  contractions 
of  a  pregnant  uterus? 

Infection  is  suggested  by  the  fever,  the  three  weeks'  cough,  and  the 
signs  in  the  left  lower  axilla,  which  are  quite  consistent  with  a  pleurisy. 

On  the  other  hand,  the  intermittence  of  the  pain  is  what  we  should 
expect  if  it  coincided  with  uterine  contractions.  The  next  thing  to  do, 
then,  is  to  watch  the  patient  continuously  with  the  hand  over  the  uterus, 
and  see  whether  the  pains  coincide  with  the  uterine  movements.  In  a 
somewhat  similar  case,  occurring  in  a  young,  neurotic  Jewess  six  and  a 
half  months  pregnant,  and  sutTering  also  from  a  moderatcl}'  a<l\anced 


124 


DIFFERENTIAL  DIAGNOSIS 


tuberculous  process  in  the  lung,  I  stood  by  the  patient,  with  my  hand 
upon  the  abdomen,  until  I  convinced  myself  that  the  lumbar  pain  was 
dependent  upon  her  restless  movements  and  not  upon  uterine  contrac- 
tions. In  this  latter  case  the  patient  went  on  to  full  term,  though  the 
tuberculous  process  developed  ominously. 

Outcome. — On  observation  the  pain  was  soon  determined  to  coincide 
with  uterine  contractions.  On  December  12th  she  gave  birth  to  a 
seven-and-a-half-pound  boy. 

Diagnosis. — Parturition. 

Case  49a 

Called  May  9th,  191 1,  to  a  girl  eight  years  of  age,  who  complained 
of  severe  pain  in  back  and  thighs,  with  difficulty  in  walking.  The 
father  is  addicted  to  the  too  liberal  use  of  intoxicants,  but  is  otherwise 
in  good  health.  Mother  in  good  health.  The  patient  is  the  third 
child  in  a  family  of  seven  children,  all  living  and  well.  On  questioning, 
it  appeared  that  two  days  before,  while  playing  at  school,  she  was 
thrown  down  a  bank ;  she  thinks  that  the  vertebrae  in  the  dorsal  region 
struck  a  stone.  No  history  of  any  previous  illness  or  injury  could  be 
obtained.  She  had  pain  in  the  back  during  the  forenoon  of  the  injury, 
and  while  walking  home  at  noon  she  lay  down  beside  the  road  for 
some  time  because  of  the  pain  in  back  and  legs,  and  the  consequent 
difficulty  in  walking.  She  felt  unable  to  return  to  school  in  the  after- 
noon, but  went  as  usual  the  next  day. 

On  the  third  day  she  was  seen  by  a  physician.  The  brows  were 
then  contracted,  the  eyebrows  raised  at  their  inner  ends,  and  the 
muscles  of  the  face  rigid.  There  was  stiffness  of  the  back  and  legs. 
When  she  was  turned  on  her  side  the  legs  would  remain  separated, 
with  no  support  for  the  upper  one  except  the  tonic  spasm  of  the 
muscles.  The  hands  were  rigidly  flexed  at  the  metacarpophalangeal 
joint.  There  was  no  anesthesia.  No  signs  of  injury  along  the  spine 
or  elsewhere  on  the  body  were  found  on  casual  examination.  At 
this  time  a  consultant  saw  the  case  and  was  unable  to  decide  be- 
tween myelitis  and  meningeal  hemorrhage. 

Next  morning  there  was  a  general  muscular  tonic  spasm,  lasting 
one  or  two  minutes,  with  involuntary  micturition  and  defecation. 
The  mind  was  perfectly  clear.  This  condition  continued  for  about 
twelve  days,  the  temperature  varying  from  100°  to  102°  F.,  with  several 
tonic  convulsions  daily.  The  jaws  were  not  tightly  closed,  but  would 
not  open  over  a  third  of  an  inch.  The  respirations  were  "grunting'' 
in  character,  and  during  the  spasms  there  was  marked  cyanosis.     No 


LUMBAR    PAIN 


125 


cough.  The  patellar  reflexes  were  present  at  the  time  of  the  first 
examination,  but  were  not  tried  for  after  that.  Physical  examina- 
tion (including  the  urine)  was  otherwise  negative. 

Discussion. — In  view  of  the  history  of  trauma  to  the  spine, 
one  thinks  first  of  some  abnormal  pressure  upon  the  cord,  perhaps  a 
hemorrhage.  But  with  hemorrhage  into  the  cord  one  would  expect 
a  more  definite  localization  of  the  symptoms  below  the  level  of  trau- 
matism. The  muscles  of  the  face  would  not  be  affected  as  they  are 
here.  Paroxysmal  and  general  tonic  spasm  is  also  uncharacteristic 
of  hemorrhage  into  the  cord.  Fracture  of  the  spine  seems  to  be 
excluded  by  the  physical  examination  and  by  the  free  power  of 
locomotion. 

In  view  of  the  presence  of  fever,  pain,  and  muscular  weakness, 
with  relaxation  of  the  sphincters,  acute  myelitis  or  poliomyeUtis  might 
be  considered.  The  latter  is  easily  excluded  by  the  absence  of  definite 
paralysis  and  the  very  widespread  tonic  spasm.  In  transverse  mye- 
litis or  difi'use  inflammation  of  the  cord,  anesthesia  or  other  sensory 
symptoms  are  almost  always  present,  and  convulsions  with  involve- 
ment of  the  face  are,  so  far  as  I  know,  unknown. 

The  muscular  spasms  present  in  this  case  have  something  in  com- 
mon with  those  seen  in  poisoning  by  strychnin,  which  may  have  been 
taken  accidentally  or  with  suicidal  intent.  Continued  fever,  however, 
is  not  usually  present  in  strychnin-poisoning.  The  face  is  not  often 
involved  and  the  sphincters  are  rarely  relaxed.  No  strychnin  was 
found  in  the  house,  and  none  had  been  given  therapeutically. 

Uremia  may  be  ruled  out  by  the  absence  of  changes  in  the  heart 
and  blood-pressure,  and  the  negative  urinary  examination. 

Epileptic  convulsions  may  occur,  as  in  this  case,  without  loss  of 
consciousness,  but  so  far  as  I  know  they  almost  always  include  clonic 
as  well  as  tonic  spasms,  whereas  in  this  case  clonic  motions  were  alto- 
gether absent.  Continuous  fever  without  loss  of  consciousness  is  also 
rare  in  epilepsy. 

Hysteria  may  produce  tonic  spasm  not  unlike  that  here  described, 
but  is  practically  never  associated  with  continued  fever  nor  with 
involuntary  micturition  and  defecation. 

A  rigidly  resistant  condition  of  all  the  muscles  is  sometimes  seen 
as  a  feature  of  the  negativism  in  dementia  i-)r;ecox.  but  this  disease  can 
here  be  ruled  out  by  the  great  suddenness  of  this  {xitient's  attack 
without  any  accompanying  or  preceding  mental  al)n()rmah'tic's,  and 
by  the  presence  of  continuous  fc\-er  and  relaxed  sphincters. 

With  the  exclusion  of  all  these  possiJjiHties  one  naturally  tomes 


126  DIFFERENTIAL   DIAGNOSIS 

to  ask  one's  self  what  infectious  disease  can  produce  fever  like  that 
here  present,  associated  with  widespread  muscular  tonic  spasm. 
Obviously  tetanus  is  such  a  disease,  but  we  have  no  history  of  any 
wound  or  injury  whereby  the  bacillus  of  tetanus  could  have  been 
introduced.  There  has  been  no  subcutaneous  injection  of  any  sub- 
stance which  could  contain  the  tetanus  bacillus  as  an  impurity  {e.  g., 
diphtheria  antitoxin,  gelatin).  Nevertheless  cases  are  on  record  in 
which  it  was  not  possible  to  discover  the  portal  of  entry  for  the  bacil- 
lus, though  such  a  portal  had  to  be  assumed,  since  the  bacillus  was  later 
isolated  from  the  tissues.  It  is  not  generally  believed  that  infection 
can  enter  through  the  gastro-intestinal  tract.  On  the  whole,  tetanus 
is  the  best  choice  among  available  alternatives. 

Outcome. — After  the  diagnosis  of  tetanus  had  been  decided 
upon  and  tetanus  antitoxin  administered,  repeated  and  prolonged 
inquiries  were  again  instituted  regarding  any  previous  injury,  and  it 
was  learned  that  two  weeks  before  the  onset  of  symptoms  there  had 
been  an  abrasion  of  the  knee  from  the  edge  of  a  rough  board;  a  sliver 
had  been  removed  and  the  wound  had  healed.  A  closer  examina- 
tion of  the  knee  was  accordingly  made;  it  revealed  a  small  bluish 
area  on  the  inner  side  of  the  right  knee,  posterior  to  the  hamstring 
and  superficially  healed  except  for  one  small  spot  from  which  a  drop 
of  pus  could  be  expressed.  This  area  was  incised  and  curetted  and 
a  further  sliver  of  wood  about  one-third  of  an  inch  in  length  was 
thus  found  and  removed.  The  wound  was  swabbed  out  with  iodin 
and  a  second  injection  of  antitoxin  administered.  No  cultures  were 
made.  On  the  fifteenth  day  of  the  illness  the  patient  was  convales- 
cent, and  twenty-four  days  from  the  onset  was  well.  There  had  been 
marked  loss  of  flesh  and  a  decidedly  round-shouldered  condition  of 
the  upper  spine  persisted;  also  occasional  muscular  pains. 

Diagnosis. — Tetanus. 


LUMBAR    PAIN 


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CHAPTER  IV 
GENERAL  ABDOMINAL  PAIN 

The  diagnosis  of  the  causes  of  abdominal  pain  is  one  of  the  most 
unsatisfactory,  as  well  as  one  of  the  most  important,  in  medicine; 
unsatisfactory,  because  our  methods  of  examination  are  so  inadequate. 
The  chest,  the  cranium,  and  the  extremities  present  far  less  difficulty, 
partly  because  their  diseases  are  more  accessible  to  direct  inspection, 
partly  because  (in  relation  to  thoracic  disease)  we  have  developed  the 
technic  of  auscultation,  percussion,  and  :x:-ray  examination  to  a  point 
quite  out  of  the  question  in  dealing  with  the  belly.  Our  methods  of 
investigating  the  abdomen  are  rough  and  primitive  compared  to  those 
for  the  study  of  the  chest. 

Aside  from  the  information  obtained  by  study  of  the  urine,  blood, 
gastric  and  intestinal  contents,  practically  all  our  knowledge  depends 
upon  palpation  and  a  good  history  of  the  case.  The  latter  is  of  crucial 
importance  in  this  diagnosis  of  gall-stones,  peptic  ulcer,  gastric  cancer, 
colica  mucosa,  and  many  other  common  diseases.  Palpation  is  mate- 
rially assisted  by  immersing  the  patient  in  a  bath  as  hot  as  he  can  bear. 
In  some  cases  the  procedure  gives  us  almost  as  complete  a  relaxation 
of  the  belly  walls  as  can  be  obtained  under  anesthesia.  It  should  be 
employed  in  all  dubious  abdominal  cases  (questionable  tumors,  unex- 
plained pains,  etc.),  especially  if  spasm  of  the  muscles  makes  ordinary 
palpation  difficult.'- 

Further  reference  will  be  made  at  the  end  of  this  chapter  to  another 
obstacle  to  correct  abdominal  diagnosis;  namely,  the  tendency  of  local 
lesions  to  produce  generalized  pain,  and  of  generalized  lesions  to  pro- 
duce localized  pain.  These  obscure  radiations  often  deceive  even  the 
expert. 

Case  50 

A  clerk  of  thirty-nine,  of  good  family  history  and  habits,  entered  the 
hospital  January  31,  1907.  He  had  rheumatic  fever  eight  years  ago. 
Three  and  one-half  years  ago  he  was  doubled  up  by  an  attack  of 
pain  and  aching  all  over  his  bowels.  He  was  seen  in  the  Brockton 
Hospital  by  Dr.  Daniel  F.  Jones,  who  said  it  was  nol  appendicitis. 
Since  this  attack  he  has  been  well  up  to  three  weeks  ago,  when,  after 
lifting,  he  had  a  stitch  in  his  back,  could  not  straighten  up,  and  had  to 

'  Women  can  be  protected  by  making  the  water  opaque  with  soapsuds. 
128 


Causes  of  General  Abdominal  Pain 


1.  CONSTIPATION 


DIARRHEA  AND 
ENTERITIS 


3.  APPENDICITIS 

4.  TYPHOID 

5.  GENERAL  PERI- 

TONITIS 

6.  LEAD-POISON- 

ING 

7.  I  NTESTI  NAL1 

OBSTRUC- 
TION, IN- 
CLUDING 
ST  RA  N  GU- 
LATED  HER- 
NIA J 

8.  TUBERCULOUS] 

PERITONITIS 
AND       TABES } 
M    E    S    E    N- 
TERICA  J 

9.  TABES     GAS-) 

TRIG  CRISIS)   i 


2761 

661 

451 
379 

237 
169 


167 


10. 


EXTRA- 

UTERINE 
PREGNANCY 


11,  N  E  U  RO  S  E  S) 


(GASTRIC) 


108 


42 


29 


11 


Among  the  rarer  causes  are  manv  varieties  of  abdominal  tumor  (which  usually  pro- 
duce /oc-ii/  rather  than  generalized  pain),  malaria  (especially  in  children),  antl  spinal  tuber- 
culosis. 


lL'!t 


GENERAL  ABDOMINAL   PAIN 


131 


stop  work.  The  pain  in  his  back  was  eased  by  lying  down,  and  has  not 
recurred.  His  bowels  have  since  been  very  costive;  hence  after  taking 
laxatives  without  result  he  took  two  injections,  which  caused  cramps  in 
the  abdomen  so  severe  that  he  "almost  went  crazy."  The  doctor  came, 
gave  him  some  "  dope,"  and  explained  that  he  had  appendicitis  or  gall- 
stones. He  is  very  nervous  and  sleeps  poorly.  He  has  sometimes  a 
voracious  appetite. 

Physical  examination  showed  good  nutrition  and  slight  pallor.  Tem- 
perature, pulse,  urine,  and  blood  normal.  The  patient  was  a  cribber. 
Physical  examination  was  entirely  negative,  except  for  slight  tenderness 
in  both  iliac  fossae.  There  was  considerable  mucus  in  the  feces,  bind- 
ing the  whole  stool  together  into  a  single  tenacious  mass,  like  sputum. 
The  patient  was  very  much  afraid  of  appendicitis,  and  complained  fre- 
quently of  terrible  pain  relieved  by  cooking  soda.  Guaiac  test  persist- 
ently negative. 

Discussion. — Appendicitis  is  and  should  be  our  first  thought  in  any 
case  beginning  with  such  symptoms,  but  the  suspicion  is  shown  to  be 
groundless  by  the  absence  of  elevation  of  the  pulse,  temperature,  or 
leukocyte  count,  and  by  the  fact  that  there  is  no  tenderness  or  spasm 
in  the  appendix  region. 

Inflammation  of  the  gall-bladder  is  ruled  out  for  similar  reasons. 

Lead  colic  is  consistent  with  all  the  symptoms  here  mentioned,  but 
no  such  diagnosis  can  l)c  made  in  the  absence  of  all  other  evidence  that 
lead  is  in  the  system  (lead-line,  stippled  red  corpuscles,  occupation  in- 
volving lead). 

Pain  relic\-ed  by  cooking  soda  is  often  the  result  of  duodenal  ulcer, 
a  disease  always  to  be  thought  of  in  patients  with  acute  abdominal 
symptoms.  The  history  and  the  physical  examination,  however,  offer 
no  confirmatory  evidence.  No  blood  has  ap])arently  been  discharged, 
either  by  the  mouth  or  by  the  l)Owels,  and  we  ha\'c  not  the  usual  history 
of  long-standing  digestive  disturbance,  r^fucous  colitis  or  coHca  mu- 
cosa is  a  diagnosis  consistent  with  all  the  symj^toms  here  described. 
The  chronic  constij)ation,  the  suggestion  of  a  neurotic  constitution, 
the  occasional  attacks  of  sexerc  al)(loi"nin;!l  ])ain,  i\nd  the  ])resence  of  a 
large  amount  of  mucus  in  the  stools  ])asse(l  soon  after  such  pain  coni- 
})lete  a  typical  picture  of  this  disease. 

Three  grouj)S  of  cases  are  often  met  in  practice: 

(i)  Those  with  much  nervousness,  some  pain,  and  sonie  nnxus. 
(2)  Those  of  much  pain,  some  nervousness,  and  some  uuicus.  'v 
Tliose  of  much  mucus,  some  ner\'ousness,  and  some  ])a;n. 

In  all   three  groups  constipation   is  tlie  underlying  factc^r.     I'reat- 


132 


DIFFERENTIAL  DIAGNOSIS 


ment  must  be  directed  to  the  relief  of  tliis  and  of  the  accompanying 
neurosis. 

Outcome. — ^His  points  of  tenderness  varied  from  day  to  day,  but  at 
no  time  did  he  have  tenderness  in  the  right  iliac  fossa.  After  his  bowels 
got  to  moving  regularly,  the  pains  disappeared  and  he  gained  4  pounds 
inside  of  a  week.  Simultaneously  his  urinary  excretion  increased  from 
30  to  60  ounces.     He  left  the  hospital  well  on  the  eleventh  of  February. 

Diagnosis. — Neurosis;  mucous  colitis. 

Case  51 

A  stenographer  of  twenty-four  entered  the  hospital  March  26,  1908. 
Six  years  ago  she  had  six  attacks  of  cramp-like  pain  in  the  abdomen, 
each  lasting  six  or  eight  hours,  and  relieved  by  morphin.  The  pain  was 
not  localized  in  any  one  place,  but  after  an  attack  she  had  soreness  in  the 
left  lower  quadrant.  Since  that  time  she  has  had  a  more  or  less  con- 
tinuous "hard  ache"  in  the  left  lower  quadrant,  never  moving  to  any 
other  place.  She  also  has  stiffness  in  both  legs  down  as  far  as  the  knees. 
Her  pain  is  not  aggravated  by  motion.  She  has  had  no  vomiting  at  any 
time.  Working  at  the  typewriter  seems  to  cause  cramp-like  pains  in  the 
stomach.  On  account  of  these  she  was  operated  on  in  August,  1907, 
for  appendicitis,  and  was  told  that  "chronic  appendicitis"  was  found 
and  cured.  The  pains  have  continued  as  before. ,  Her  appetite  and 
sleep  are  good,  but  she  is  markedly  constipated.  Last  August  she 
weighed  126  pounds;  now  she  weighs  118.  She  often  has  pain  on  mic- 
turition, and  occasionally  difficulty  in  passing  her  urine. 

On  physical  examination  her  pupils  are  widely  dilated,  equal,  and 
react  normally.  The  gums  are  normal.  There  is  a  short,  rough, 
systolic  murmur  heard  all  over  the  precordia  and  in  the  left  axilla. 
There  is  no  enlargement  of  the  heart  nor  accentuation  of  the  pulmonic 
second  sound.  The  abdomen  is  negative;  likewise  the  blood,  urine, 
temperature,  pulse,  and  respiration. 

Discussion. — The  gist  of  this  case  seems  to  be:  non-localized  ab- 
dominal pain,  with  a  negative  physical  examination  in  all  essentials. 
Lead-poisoning  is  easily  ruled  out  by  the  absence  of  changes  in  the  blood 
or  in  the  gums.  Since  the  pupils  react  normally,  tabes  dorsalis  seems 
very  unlikely,  though  tliere  is  nothing  said  about  the  reflexes  in  the 
description  as  given  above. 

Dilatation  of  the  pupils  is  common  in  a  great  variety  of  psycho- 
neurotic states;  nevertheless,  it  should  always  suggest  the  possibility  of 
a  cocain  habit,  especially  if  any  heart  trouble  is  complained  of  or  comes 


GENERAL  ABDOMINAL  PAIN  1 33 

to  light  on  physical  examination.  In  the  present  case  there  was  no  such 
evidence,  and  the  habit  was  firmly  denied. 

In  a  considerable  number  of  cases  of  pulmonary  tuberculosis  there 
is  dilatation  of  one  or  both  pupils,  and  the  presence  of  this  sign  always 
leads  me  to  examine  the  pulmonary  apices  with  particular  care.  In 
this  case  such  an  examination  was  negative. 

The  controverted  question  of  chronic  appendicitis  is  raised  afresh  in 
this  case,  but  I  suppose  no  one  will  maintain  that  an  appendix  can 
produc'e  symptoms  seven  months  after  it  has  been  removed.  When 
the  patient's  symptoms  persist  unchanged  after  the  removal  of  a  so- 
called  chronic  appendix,  it  is  generally  agreed  upon  that  in  this  case 
the  appendix  was  not  the  cause  of  the  symptoms.  Indeed,  this  is  one  of 
the  few  points  regarding  chronic  appendicitis  on  which  physicians  do 
very  generally  agree.  Personally,  I  believe  that  in  a  considerable  pro- 
portion of  the  cases  operated  upon  as  chronic  appendicitis  the  ap- 
pendix has  nothing  to  do  with  the  symptoms.  The  disappearance  of 
symptoms  following  operation  is  not  ahvays  a  proof  that  the  appendix 
was  the  offending  member.  The  operation  itself,  with  the  postoperative 
rest,  diet,  physical  and  mental  training,  may  well  have  been  the  cause 
of  the  relief. 

In  the  present  case,  if  we  take  account  of  the  age  and  sex,  the  marked 
constipation,  and  the  variety  of  "wild  symptoms,"  such  as  painful 
micturition  and  stiffness  of  the  legs,  it  seems  more  than  likely  that  a 
general  neurosis  based  on  faulty  habits  and  unfortunate  environment 
is  at  the  root  of  all  the  troubles.  The  domestic  and  industrial  back- 
ground should  be  looked  into. 

Outcome. — On  further  investigation  it  appeared  that  insufficient 
food,  hurry,  worry,  and  sedentary  occupation  in  a  close  office  had  much 
to  do  with  her  condition.     All  the  rellexes  were  lively. 

Diagnosis. — Bad  hygiene. 

Case  52 

A  Russian  Jew,  apparently  without  occupation,  forty-eight  years  oki, 
entered  the  hospital  December  26,  1907.  For  seven  \vceks  he  has  Ixcn 
having  pain  and  "burning"  in  the  center  of  the  abdomen,  not  very  scvcv:', 
but  constant  and  worse  at  night,  though  he  sleeps  well.  It  is  worse,  also, 
immediately  after  eating.  His  appetite  is  ]X)or;  he  has  taken  nolViiiig 
but  a  little  milk  of  late.  Ilis  1)0wels  arc  very  irregular,  usikiII}'  con- 
stipated.    He  does  not  vomit  or  cough. 

On  physical  examination  a  regularly  distribuled.  rose-colori'd  macular 
eruj)tion  is  found  in  various  [)arts  of  his  bcxly,  antl  there  aie  marks  of 


134 


DIFFERENTIAL  DIAGNOSIS 


scratching  on  the  upper  arms.  The  chest  shows  nothing  abnormal. 
Beneath  the  umbilicus,  and  extending  out  toward  the  right  flank,  is  a 
smooth,  rounded,  cyUndric  mass,  about  three  inches  long,  one  and  a 
half  inches  wide,  freely  movable,  not  hard  or  tender,  feeling  not  unlike 
a  kidney.  Physical  examination,  including  the  blood,  urine,  tempera- 
ture, pulse,  and  respiration,  is  otherwise  entirely  negative. 

Discussion. — The  important  objective  findings  are  the  macular 
eruption  and  the  cylindric  mass  in  the  abdomen;  the  former  suggests 
syphilis,  the  latter,  an  abdominal  tumor.  Against  syphilis,  however,  is 
the  itching  of  the  eruption,  as  evidenced  by  scratch-marks.  There  is 
also  no  evidence  of  a  primary  lesion,  and  the  patient  denies  all  knowledge 
of  the  disease. 

Russian  Jews  in  general,  and  unoccupied  Russian  Jews  in  particu- 
lar, are  very  prone  to  neuroses  and  vague  unexplained  pains.  It  is 
striking  how  often  they  refer  to  these  pains  as  "burning."  "Es  brennt 
mir  das  Herz,"  or  "Es  brennt  mir  iiberall,"  are  very  common  com- 
plaints among  them. 

It  is  noteworthy  also  that  this  pain,  though  worse  at  night,  does  not 
prevent  him  from  sleeping  well. 

Turning  now  to  the  abdominal  mass,  we  note  that  it  occupies  the 
position  in  which  a  displaced  kidney  is  often  to  be  felt,  especially  in 
women.  It  seems,  however,  rather  too  short  and  too  little  sensitive. 
In  view  of  his  chronic  constipation  a  mass  of  retained  feces  may  well  be 
the  explanation.  It  seems  reasonable,  then,  to  explain  his  indigestion, 
eruption,  and  anorexia  as  the  result  of  constipation,  the  latter  in  turn 
being  the  commonest  of  all  manifestations  of  a  general  neurosis. 

Outcome. — The  patient  was  given  an  A.  S.  and  B.  pill,  and  the  next 
morning  the  tumor  had  entirely  disappeared.  The  following  day  it 
w^as  again  felt  just  at  the  level  of  the  umbilicus,  and  considerably  smaller 
than  at  entrance.  Similar  masses  were  then  felt  in  the  left  iliac  fossa. 
These  also  disappeared  with  free  movements  of  the  bowels.  On  Decem- 
ber 31st  his  abdomen  was  wholly  negative,  his  eruption  gone,  and  he 
had  a  wonderful  appetite. 

Diagnosis. — Constipation. 

Case  53 

A  storekeeper  of  twenty-six,  of  good  family  history  and  habits, 
entered  the  hospital  October  17,  1907,  stating  that  he  had  always  had  a 
weak  stomach  and  had  been  troubled  by  pains  in  the  chest  and  limbs 
off  and  on  for  the  past  ten  years.  Nevertheless  he  kept  about  and  did 
his  work  in  this  condition  until  January,  1907,  when  he  was  confined  to 


GENERAL  ABDOMINAL   PAIN 


135 


bed  for  fifteen  days  by  an  attack  of  pain  "in  the  lungs  and  back."  In 
March  he  was  again  confined  to  bed  for  two  days  with  pain  across  the 
upper  abdomen.  In  April  and  May  he  felt  poorly,  but  kept  at  work. 
In  June  he  first  noticed  general  abdominal  tenderness  and  considerable 
enlargement,  with  painful  micturition.  He  was  then  in  bed  for  three 
weeks.  After  that  he  worked  until  August,  when  he  was  suddenly 
taken  with  violent  headache,  chills,  sharp  pain  under  the  left  breast,  in 
the  back  and  in  the  loins,  with  enlargement  of  the  abdomen.  He 
remained  in  bed  thirty-five  days,  his  temperature  rising  every  afternoon 
to  102°  F.  or  102.5°  F.  He  sweated  profusely  every  night.  Since  then 
he  has  been  poorly  and  his  night-sweats  have  continued,  but  the  size  of 
his  belly  has  diminished.  During  the  past  nine  months  he  has  lost 
II  pounds  in  weight.  He  had  at  times  a  slight  cough,  with  sputa  rarely 
blood-specked.  During  the  past  few  days  there  has  been  slight  swell- 
ing of  his  legs. 

Examination  of  the  lungs  and  heart  showed  nothing  abnormal. 
The  abdomen  was  symmetrically  distended;  there  was  slight  tympany 
in  the  flanks;  the  belly  elsewhere  was  dull,  tense,  firm,  slightly  tender 
throughout.  There  was  vague  resistance  at  and  about  the  umbilical 
region. 

The  blood  and  urine  showed  nothing  abnormal,  and  the  temperature, 
pulse,  and  respiration  were  not  elevated  during  the  seven  weeks  of  his 
stay  in  the  hospital.  After  the  injection  of  5  milligrams  of  tuberculin 
there  was  no  rise  of  temperature,  but  he  felt  sick  and  weak,  and  his  belly 
became  much  more  tender. 

Discussion. — Chronic  abdominal  pain  and  tenderness,  with  fever 
and  sweating,  form  a  clinical  picture  characteristic  of  very  few  diseases 
occurring  in  the  male  sex.  Subphrenic  abscess  may  produce  such  symp- 
toms, but  not  without  further  physical  signs,  either  in  the  abdomen, 
near  the  costal  margin,  or  in  the  chest  through  displacement  of  the  dia- 
phragm. Perforative  peritonitis  could  not  be  so  chronic  without  either 
healing  or  killing. 

T}q^hoid  fever  might  produce  such  a  pyrexia,  and  would  account  for 
most,  if  not  all,  of  the  abdominal  symptoms,  but  during  his  stay  in  the 
hospital  his  abdominal  symptoms  continued  despite  the  absence  of  all 
fever.     Ty])hoid  would  not  explain  this. 

Can  he  be  suffering  from  chronic  intestinal  obstruction?  The 
abdominal  pain  and  distention  suggest  it,  but  his  bowels  Innc  mowd 
regularly  througiiout.  There  has  been  no  vomiting,  visible  peristalsis. 
or  other  evidence  of  local  lesion. 

In  my  own  ex])erience  there  are  only  two  diseases  which  present  a 


136  DIFFERENTIAL  DIAGNOSIS 

clinical  picture  at  all  like  this:  (a)  The  psycho-neurotic  state,  and  {b) 
abdominal  tuberculosis.  Since  the  former  can  be  ruled  out  by  the  five 
weeks  of  daily  fever,  only  one  diagnosis  seems  reasonable. 

Outcome. — On  the  second  of  November  the  spine  of  the  fifth  dorsal 
vertebrae  was  found  to  be  very  tender  on  pressure.  This,  in  connection 
with  the  fact  that  sitting  erect  caused  sharp  pains  in  the  chest  and 
abdomen,  suggested  spinal  tuberculosis,  but  an  orthopedic  consultant 
thought  it  more  likely  to  be  glandular  tuberculosis  in  the  abdomen. 

Two  other  consultants  thought  the  symptoms  probably  due  to 
chronic  appendicitis. 

On  the  sixth  of  December  the  abdomen  was  opened,  and  the  in- 
testines found  to  be  everywhere  adherent  to  each  other,  to  the  omen- 
tum and  to  the  abdominal  wall.  A  large  chain  of  glands  was  matted 
together  in  the  appendix  region,  and  many  others  were  scattered  about. 
There  was  no  fluid.  Microscopic  examination  of  a  piece  excised  showed 
tuberculosis. 

Diagnosis. — Peritoneal  tuberculosis. 

Case  54 

A  housewife  of  forty-four  who  had  been  in  the  hospital  in  May,  1905, 
and  been  operated  on  for  inflamed  tubes  and  ovaries  (which  were 
removed),  chronic  appendicitis,  and  sigmoid  adhesions,  entered  the 
hospital  February  20,  1908.  Ever  since  May,  1905,  the  symptoms 
which  then  led  to  operation  have  persisted.  She  has  been  treated  in 
the  medical,  surgical  and  orthopedic  departments  for  out-patients,  and 
has  worn  flat-foot  plates  and  abdominal  supporters  without  relief. 
She  has  been  unable  to  do  any  work  on  account  of  soreness  in  the  lower 
abdomen,  together  with  sharp  attacks  of  pain  starting  in  the  back  and 
passing  around  the  sides  to  the  center  of  the  abdomen.  These  attacks 
come  on  when  she  steps  or  moves  quickly,  even  when  she  turns  o\'er  in 
bed  at  night.  The  pain  is  somewhat  less  sharp  when  her  bowels  are 
open,  but  she  is  exceedingly  constipated.  She  complains  of  a  "drawing, 
scratching"  feeling  in  her  bowels,  as  if  they  were  trying  to  move,  but  could 
not.  She  has  gained  20  pounds  since  the  operation  at  ^vhich  the  tubes 
and  ovaries  were  removed. 

Physical  examination  shows  extreme  obesity,  slight  tenderness  in 
the  left  lower  quadrant  of  the  abdomen,  and  nothing  else,  except  slight 
soft  edema  over  the  shins. 

Discussion. — In  an  analysis  of  "One  Hundred  Christian  Science 
Cures,"  printed  in  McClure's IMagazine  for  August,  1908,  I  pointed  out 
that  patients  who  have  had  many  doctors  and  many  diagnoses  are  very 


GENERAL  ABDOMINAL  PAIN 


137 


apt  to  be  successfully  rounded  up  and  cured  by  Christian  Science,  owing 
to  the  fact  that  in  such  cases  no  organic  disease  is  present. 

The  history  of  the  present  patient  and  of  the  vicissitudes  through 
which  she  passed  suggest  that  she  belongs  in  this  group.  Doubtless 
many  of  her  symptoms  represent  only  the  discomforts  inseparable  from 
extreme  obesity,  especially  when  it  is  associated  with  constipation. 

If  this  be  true,  the  question  may  be  asked  how  the  edema  of  the 
leg  is  to  be  accounted  for,  but  I  think  it  is  generally  recognized  that  obesity 
is  in  itself  sufl&cient  to  account  for  such  a  swelling,  without  supposing 
any  insufficiency  of  the  heart  or  kidneys. 

Doubtless  this  patient's  symptoms  are  due  in  part  to  the  nervous 
instability  often  following  the  removal  of  the  ovaries,  but  the  constipa- 
tion, the  obesity,  and  the  firmly  acquired  "doctor  habit"  are  also  im- 
portant factors. 

Such  a  diagnosis,  though  satisfactory  enough  from  our  point  of  view, 
may  be  of  very  little  use  to  the  patient,  whose  sufferings  often  go  on 
unabated  unless  we  can  succeed  in  the  almost  superhuman  task  of 
changing  most  of  her  habits,  mental  and  physical. 

Outcome. — ^When  the  patient  is  alone  in  the  ward,  she  does  not  seem 
to  suffer,  but  her  complaints  are  very  numerous  whenever  a  doctor  or  a 
nurse  approaches.  She  complains  that  she  is  restless  at  night,  but 
snores  loudly.  A  tight  abdominal  binder  and  vibratory  massage 
had  relieved  her  considerably  by  the  eleventh  of  March. 

Diagnosis. — Postoperative  neurosis. 

Case  55 

A  school-boy  of  nine  was  first  seen  September  23,  1907,  with  the  state- 
ment that  he  had  never  been  sick  before,  except  that  six  months  ago  he 
had  an  attack  similar  to  the  present.  Seven  days  ago  he  began  to  ha\"e 
general  abdominal  pain.  Five  days  ago  the  pain  was  much  aggra\ated, 
and  seemed  to  be  more  troublesome  on  the  right  side  of  the  abdomen. 
Four  days  ago  he  had  a  sore  throat.  His  ai)])etite  has  been  good;  his 
bowels  regular.     He  has  had  no  headache  or  nausea. 

Fxamination  Se])tembcr  23d  was  negati\e,  exce]>t  for  a  tem])erature 
of  103.6°  F.,  and  the  leukocyte  count  of  22,000.  with  a  negative  Widal 
reaction.  There  was  at  that  time  slight  tenderness  at  and  abo\e 
McRurney's  point. 

September  26th  the  fever  still  continued;  ])hysical  examination  was 
negative  in  all  respects.  The  Widal  reaction  was  negative;  white  cells, 
CS400;  the  course  of  the  temperature  was  as  shown  in  the  accompanying 
chart. 


138 


DIFFERENTIAL  DIAGNOSIS 


Discussion. — During  the  eariy  days  of  my  attendance  on  this  case 
I  could  make  no  diagnosis.  The  fever,  the  leukocytosis,  and  the  ab- 
dominal signs  favored  appendicitis,  though  the  absence  of  all  spasm 
and  of  all  but  very  slight  tenderness  in  the  appendix  region  made  this 
doubtful.  The  sore  throat  was  practically  gone  before  I  saw  him,  and 
could  not  be  held  responsible  for  the  symptoms  then  present. 

On  the  twenty-sixth,  however,  the  clinical  picture  had  quite  changed. 
Continued  fever  with  a  low  white  count  and  a  negative  tuberculin  reac- 
tion were  now  the  essential  features.  This  means,  in  all  probability, 
either  typhoid  fever  or  some  of  the  unknown  infections  unwisely  called 
"febricula"  or  ''grip."     The  latter  possibilities  were  soon  ruled  out 


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Fig.  25. — Chart  of  case  55. 


by  the  long  duration  of  the  fever.  Under  the  hypothesis  of  typhoid  fever 
it  was  left  for  us  to  explain  the  initial  leukocytosis  and  the  absence  of  the 
Widal  reaction.  No  such  explanation,  however,  was  then  forthcoming. 
The  phenomena  just  referred  to  remained  as  examples  of  the  wild, 
untamed,  residual  items  so  characteristic  of  any  accurately  described 
case  of  illness. 

Outcome. — On  the  third  of  October  the  Widal  reaction  appeared. 
On  the  eighth  he  was  given  a  drop  of  tuberculin  in  the  left  eye,  without 
any  subsequent  reaction. 

On  Xovember  gth  he  was  discharged  well. 

Diagnosis. — Tyyihoid. 


GENERAL  ABDOMINAL  PAIN 


139 


Case  56 

A  Portuguese  housewife  of  thirty-two  entered  the  hospital  October 
25,  1907,  with  a  negative  family  history  and  good  habits.  She  had  a 
miscarriage  two  years  ago,  and  two  other  miscarriages  since  her  marriage 
three  years  ago.  She  has  one  healthy  child.  For  seven  years  she  has 
been  subject  to  general  abdominal  pain,  not  severe. 

Three  weeks  ago  she  began  to  have  dull,  steady  pain,  starting  in  the 
left  lower  quadrant,  whence  paroxysms  of  more  severe  pain  extended 
across  the  abdomen  and  up  both  sides  of  the  chest  to  the  neck.  The 
appetite  is  poor;  there  is  occasional  nausea,  but  no  vomiting.  The 
bowels  are  constipated.  For  the  past  three  weeks  micturition  has  been 
somewhat  painful. 

Physical  examination  shows  obesity.  The  chest  is  normal,  the 
abdomen  tympanitic  in  the  upper  part,  dull  in  the  lower  part,  where 
tenderness  is  so  great  that  palpation  is  impossible.  The  blood-pressure 
is  100  millimeters  of  mercury;  the  white  count,  14,900.  Urine,  tem- 
perature, pulse,  and  respiration  are  normal.  During  the  week  of  her 
stay  in  the  hospital  she  complained  of  pain  in  every  part  of  her  body. 

Discussion. — Syphilis  is  the  first  possibihty  that  occurs  to  us  in  this 
case,  in  view  of  the  frequent  miscarriages.  It  is  impossible,  however, 
to  incriminate  any  particular  organ  or  to  obtain  any  more  definite  history 
of  the  disease,  which  must  remain  in  the  background  as  a  possibility 
incapable,  at  present,  of  further  verification. 

We  naturally  ask  ourselves  next  whether  the  alsdominal  tenderness 
and  painful  micturition  are  not  due  to  gonorrheal  infection  of  the  tubes 
and  bladder.  This  ])ossibility  cannot  be  absolutely  excluded,  but  in  the 
absence  of  fever,  leukocytosis,  and  urinary  changes,  it  seems  decidedly 
unlikely. 

The  very  wide  distribution  and  radiation  of  the  pain,  and  its  asso- 
ciation with  vomiting,  constipation,  and  anorexia,  lead  us  to  conclude 
that  if  any  infiammatory  lesion  has  existed  in  the  pelvis  it  is  now  burnt 
out  and  exerting  its  eO'ect  chiclly  through  the  nervous  system. 

Outcome. — A  few  nights  before  her  discharge  she  was  rolling  and 
groaning  with  pain,  but  a  subcutaneous  injection  of  sterile  water  ga\e 
immediate  relief.     Vaginal  tampons  also  improved  her  mental  condition. 

Obviously,  the  thera])eutic  test  was  here  of  considerable  diag- 
nostic value.  T  believe,  ho\ve\-er,  tliat  the  same  im])()rtant  information 
can  be  obtained  througli  tlie  in\estigati()n  of  the  ])sychic  state,  and 
without  anv  of  the  charlatanry  wiiich  seems  to  me  inherent  in  the  niethcKls 
here  employed. 

Diagnosis. — Neurosis. 


I40 


DIFFERENTIAL  DIAGNOSIS 


Case  57 


A  factory  girl  of  twenty-six,  a  Canadian  by  birth,  was  first  seen 
May  28,  1907.  In  April,  1906,  she  had  a  sickness  similar  to  the  present 
one.  At  that  time  medication  gave  no  relief,  but  a  six  weeks'  vacation 
in  Roxbury  entirely  relieved  her.     Her  home  is  in  Blackstone,  Mass. 

In  March,  1907,  she  began  to  have  dull,  colicky  pain  and  tenderness 
in  the  lower  part  of  her  abdomen,  constant,  showing  no  relation  to  meals 
nor  to  the  kind  of  food  eaten,  often  keeping  her  awake  at  night,  usually 
relieved  by  pressure.     Frequently  she  has  to  sleep  upon  her  belly  all 

night.    With  the  pain  she  has  constipation, 
and  has  noticed  that  she  is  getting  pale. 

On  physical  examination  the  abdomen 
was  full,  soft,  tympanitic  throughout,  and 
showed  no  tenderness  at  any  point.  The 
chest  was  likewise  normal.  A  blood-smear 
showed  60  per  cent,  hemoglobin,  some 
achromia  and  many  stippled  cells. 

The  urine  averaged  about  25  ounces  in 
twenty-four  hours,  and  contained  a  trace 
of  albumin,  many  hyaline  and  granular 
casts  with  an  occasional  cell  adherent. 

Discussion. — Although  this  case  puz- 
zled a  number  of  physicians,  there  would 
have  been  no  puzzle  about  it  but  for  the 
neglect  of  a  routine  blood  examination, 
for  there  is  only  one  disease  which  often 
produces  basophilic  stippling  of  the  red 
cells  in  the  absence  of  marked  anemia. 
That  disease  is  chronic  lead-poisoning.  Other  diseases  (e.  g.,  diabetes) 
have  been  known  to  produce  a  similar  blood-picture,  but  this  is  rare. 

Lead-poisoning  is  a  very  common  disease,  but  the  failure  to  recognize 
it  is,  in  my  experience,  still  commoner.  This  is  not  because  it  is  difficult 
of  diagnosis,  for  the  very  reverse  is  the  case,  but  because  physicians  so 
often  fail  to  suspect  its  possibility  and  to  examine  patients  for  definite 
e\'idence  of  its  presence.  When  once  our  attention  is  turned  toward  this 
diagnosis,  we  shall  note,  as  in  the  present  case,  a  very  striking  group  of 
confirmatory  signs.  A  chronic  abdominal  pain  relieved  by  pressure 
would  be  likely  to  have  more  relation  to  meals  if  it  were  due  to  duodenal 
ulcer  or  to  any  cause  other  than  lead.  Association  with  constipation, 
pallor,  and  albuminuria  should  certainly  make  us  search  for  a  lead  line 


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Fig.  26. — Chart  of  case  57. 


GENERAL   ABDOMINAL   PAIN  14I 

on  the  glims — one  of  the  signs  which  is  most  often  forgotten  In  routine 
physical  examination. 

Outcome. — The  gums  showed  a  typical  lead  line.  Her  mother  and 
sister  have  a  similar  but  less  severe  trouble.  The  patient  was  given 
magnesium  sulphate,  an  ounce  every  morning;  iodid  of  potash,  5  grains 
three  times  a  day,  and  an  occasional  dose  of  morphin  and  atropin  \vas 
also  needed.     Turpentine  stupes  relieved  her  pain  more  or  less. 

By  June  6th  her  appetite  had  improved,  her  cramps  were  gone,  and 
her  color  had  begun  to  return. 

By  the  ninth  of  June  she  was  ready  to  go  home.  It  appeared  that 
the  whole  family  got  their  water  from  a  well  through  a  lead  pipe  75  feet 
long. 

The  reader  will  note  the  striking  rise  in  pulse-rate  and  its  continued 
rapidity  after  the  first  week  of  treatment.  The  bradycardia  of  plumb- 
ism  has  often  been  recorded,  but  never,  I  think,  satisfactorily  explained. 

Diagnosis. — Lead-poisoning. 

Case  58 

An  Italian  meat-cutter  of  thirty-five  was  seen  June  20,  1907.  He 
stated  that  he  had  never  been  sick  before  until  a  year  and  a  half  ago 
(six  months  after  his  arrival  in  this  country),  when  he  began  to  notice  that 
his  abdomen  was  slightly  larger  than  normal.  He  also  noticed  a  beating 
in  the  pit  of  the  stomach  with  vague  abdominal  pains,  much  loss  of 
strength,  occasional  chills,  and  slight  fever.  At  times  his  abdomen  has 
seemed  to  be  swollen,  but  of  late  it  has  been  smaller.  The  pain  is  steady, 
dull,  worse  on  dark,  cold  days.  He  is  easily  fatigued  and  has  done  no 
work  for  six  months,  but  his  weight  has  remained  steady.  He  has  had 
dizziness  and  buzzing  in  his  head  for  three  months,  and  for  one  month 
night-sweats.  He  eats  and  sleeps  well,  but  his  bowels  move  only  with 
laxatives. 

Physical  examination  of  the  chest  was  negative.  The  abdomen 
showed  dulness  in  the  left  flank,  which,  however,  did  not  shift  with 
change  of  position.  There  was  slight  tenderness  in  the  region  of  the 
umlnlicus.  Near  this  tender  point  a  violent  pulsation  was  felt,  synchro- 
nous with  the  heart-beat.  It  was  expansile  in  character,  and  during  pal- 
pation a  systolic  thrill  could  be  appreciated  over  it.  A  systolic  murnuir 
was  audible  at  the  same  site.  The  tuberculin  reaction  (subcutaneous) 
was  entirely  negative.  The  urine  averaged  about  22  ounces  in  twrnty- 
four  liours,  was  free  from  iilbumin,  but  contained  rare  hyaline  and  gran- 
ular casts.  Blood  examination  was  negatixe;  white  cells,  7000.  Tem- 
perature, ])ulse,  and  respiration  were  normal. 


142 


DIFFERENTIAL  DIAGNOSIS 


Discussion. — In  the  presence  of  chronic  abdominal  pain  with  swell- 
ing of  the  abdomen,  weakness,  night-sweats,  and  constipation,  the  pos- 
sibility of  tuberculous  peritonitis  should  always  be  entertained,  espe- 
cially when  the  patient  is  an  Italian  recently  settled  in  America.  In  the 
present  case,  however,  the  absence  of  fever  at  the  present  time,  the 
negative  tuberculin  reaction,  and  the  fact  that  no  characteristic  lesions — 
either  of  "dry"  or  of  "wet"  tuberculosis — can  be  detected  in  the  abdo- 
men make  this  diagnosis  unlikely. 

More  plausible  is  the  idea  of  aortic  aneurysm,  and  this  was,  in  fact, 
the  diagnosis  of  the  attending  physician.  Against  it,  however,  were 
two  very  important  facts:  the  pain  was  in  the  wrong  place  and  there 
was  no  tumor.  The  pain  of  abdominal  aneurysm  is  almost  entirely  in 
the'  back  and  legs.  Further,  the  diagnosis  of  aneurysm  is  never  well 
grounded  unless  we  can  feel  a  definite  tumor  with  a  beginning,  middle, 
and  end.  However  violent  the  pulsation  we  may  find  in  the  abdomen, 
— and  I  have  seen  it  sufficient  to  shake  the  bed  in  which  the  patient  lay, — 
we  have  no  right  to  make  the  diagnosis  of  aneurysm  unless  we  have,  in 
addition  to  the  pulsation,  a  definite  tumor  or  severe  pain  in  the  back. 
Expansile  pulsation,  thrill,  and  systolic  murmur  can  be  appreciated  over 
any  abdominal  aorta  which  is  superficial  enough  to  be  reached  with  the 
fingers  and  with  the  stethoscope. 

It  seems  almost  incredible  that  an  illness  so  prostrating  as  this 
could  be  produced  by  the  mere  accident  of  having  one's  attention  di- 
rected to  the  normal,  though  lively,  pulsation  of  one  of  one's  own  blood- 
vessels; but  such  was  really  the  case  here.  Dynamic  aorta — that  is, 
a  somewhat  unusual  liveliness  in  the  pulsation  of  a  perfectly  normal 
blood-vessel  in  a  person  of  neurotic  constitution — is  very  frequently 
mistaken  for  abdominal  aneurysm.  Indeed,  I  should  say  that  five  out 
of  every  six  cases  in  which  I  have  known  the  diagnosis  of  abdominal 
aneurysm  to  be  made  have  turned  out  to  be  nothing  but  dynamic  aorta. 
Nothing  but  the  experience  of  following  such  a  case  to  complete  and 
lasting  recovery,  as  the  result  of  the  policy  of  disregarding  all  the  symp- 
toms and  turning  the  attention  in  other  directions,  can  convince  the 
patient  and  his  physician  of  the  facts  just  quoted. 

In  true  abdominal  aneurysm  the  tumor  is  seldom  in  the  median  line. 
It  is  much  larger  and  more  globular,  and  pulsates  less  violently  than  the 
dynamic  aorta.  One  of  the  most  astonishing  things  about  the  latter 
is  that  it  often  appears  just  beneath  the  skin  of  the  abdominal  wall, 
seemingly  separated  from  our  finger-tips  only  by  the  thickness  of  a  piece 
of  blotting-paper.  As  we  recall  our  dissecting-room  experiences,  it 
does  not  seem  possible  that  the  aorta  can  lie  so  close  to  the  abdominal 


GENERAL  ABDOMINAL   PAIN 


=  43 


wall.  Doubtless  this  is  due  to  a  somewhat  atypical  curve  of  the  spinal 
column. 

There  can  be  no  doubt,  I  think,  that  three  factors  enter  into  the  pro- 
duction of  the  neurosis  known  as  dynamic  aorta: 

(i)  An  unusually  superficial  position  of  the  abdominal  aorta. 

(2)  A  sensitive  and  impressionable  temperament,  such  as  shows 
itself  in  rapid  bodily  motion,  quick  excitable  speech,  lively  knee-jerks 
and  easily  excited  heart  action. 

(3)  The  abnormal  concentration  of  attention  upon  the  pulsation. 
This  latter  condition  is  favored  by  the  physician's  obvious  interest  and 
concern,  as  expressed  in  his  careful  and  repeated  examinations  of 
the  part,  his  overclouded  countenance,  and  sometimes  his  unguarded 
utterances.  If  by  any  mischance  the  patient  begins  to  suspect  that  he  has 
an  aneurysm,  he  is  pretty  sure  to  learn  from  a  dictionary  or  otherwise 
what  the  disease  really  means.  Thereafter  he  passes  his  days  and  nights 
feeling  very  much  as  though  he  had  inside  of  him  a  dynamite  bomb 
which  might  explode  at  any  minute.  This,  of  course,  reacts  upon  his 
mental  condition,  and  makes  him  watch  himself  all  the  more  care- 
fully, thereby  increasing  the  pulsation  and  soon  leading  to  the  develop- 
ment of  pain;  but  it  should  be  reiterated  that  the  pain  is  in  the  spot  to 
which  his  attention  has  been  directed,  and  not  in  the  place  where  it 
would  be  were  aneurysm  really  present. 

I  have  dwelt  at  considerable  length  upon  the  nature  of  this  trouble 
and  the  means  of  its  recognition,  because  it  is  by  no  means  uncommon, 
is  prone  to  lead  to  a  great  deal  of  unnecessary  misery  when  mistaken  for 
aneurysm,  and  because  it  is  not  treated  at  any  length  in  most  text-books. 

Outcome. — Gas  in  the  abdomen  and  the  perception  of  the  ])ulsaling 
artery  were  ai:)parently  the  cause  of  his  symptoms.  This  was  cxj)kiined 
to  him,  and  by  June  27th  he  was  free  from  complaint.  He  returned  to 
work  after  ten  days  more  and  has  since  (1910)  remained  well. 

Diagnosis. — Dynamic  aorta. 

Case  59 

A  printer  of  twenty-seven  entered  the  hos])ital  August  19,  1Q07. 
His  family  history  and  habits  are  good.  He  states  that  he  had  ''renal 
colic"  last  May  for  two  days,  and  has  since  tlien  l)een  well.  Two  weeks 
ago  his  bowels  began  to  ])e  ratlier  loose.  1  lis  api)etite  has  remaiiU'd  i:ood 
and  he  has  slept  well.  Beginning  this  morning  he  lias  liad  sewre  ali- 
dominal  cram])S,  his  bowels  ha\-e  moved  six  times,  and  he  has  Noniited 
six  times.     Tlie  ])ain  is  felt  throughout  the  alxlonn-n. 

IMivsical  examination  sliows  two  "'lands  the  si/.e  of  marbles  in  tlie 


144  DIFFERENTIAL  DIAGNOSIS 

right  axilla.  No  other  glands  seem  to  be  enlarged.  There  is  a  soft 
systolic  murmur  at  the  heart's  apex.  The  chest  is  otherwise  negative. 
The  abdomen  is  slightly  retracted.  There  is  general  muscular  rigidity, 
especially  in  the  epigastrium,  and  in  the  right  side  near  the  navel.  On 
percussion  the  belly  is  tympanitic,  except  in  the  left  flank — no  definite 
mass  or  tenderness  found.  Temperature  at  entrance  99.8°  F.;  white 
count,  16,600,  with  96  per  cent,  of  polynuclear  cells.  The  next  day 
the  temperature  and  the  white  count  were  normal.  The  diarrhea  had 
ceased. 

Discussion. — What  further  evidence  should  be  searched  for  in  this 
case?  In  any  printer  who  complains  of  abdominal  pain  we  should  at 
once  look  for  a  lead  line  on  the  gums  and  search  for  basophilic  granula- 
tions in  the  stained  blood-smear.  Both  these  lesions  were  absent  in  this 
case.  The  presence  of  diarrhea  is  also  very  uncommon  in  lead-poison- 
ing. 

An  ^c-ray  examination  is  indicated  in  view  of  the  patient's  statement 
that  he  had  renal  colic  a  few  months  before.  There  is  nothing,  how- 
ever, pointing  to  any  such  disease  in  a  physical  examination. 

Perforative  peritonitis  would  account  for  the  pain,  vomiting,  fever, 
leukocytosis,  spasm,  and  tenderness,  but  the  presence  of  a  diarrhea  with 
good  appetite  and  sleep  makes  this  very  unlikely,  especially  as  there  is 
no  local  point  of  maximum  pain  and  tenderness. 

But  for  the  definite  evidence  afforded  by  the  blood  examination,  it 
would  be  necessary  to  consider  an  acute  lymphoid  leukemia.  I  have 
seen  leukemia  presenting  the  symptoms  here  described  with  no  more 
striking  glandular  enlargement.  The  blood  examination,  however, 
was  distinctive. 

Why  should  it  not  be  a  simple  gastro-enteritis,  especially  in  view  of 
the  time  of  year  at  which  the  symptoms  occurred?  Severe  abdominal 
cramps,  a  general  muscular  rigidity  in  the  abdomen,  transitory  fever 
and  leukocytosis  are  all  quite  consistent  with  that  diagnosis;  there 
seems  to  l)e  nothing  of  importance  against  it. 

Outcome. — X-ray  showed  no  evidence  of  renal  calculus,  after  rest 
in  bed  and  regulated  diet,  ten  half-grain  doses  of  calomel,  and  an  ounce 
of  magnesium  sulphate,  the  patient  was  discharged  well  on  the  twenty- 
second. 

Diagnosis. — x'Vcute  gastro-enteritis. 

Case  60 

A  teamster  of  forty-four,  with  a  negative  family  history,  was  first 
seen  August  24,  1907. 


GENERAL  ABDOMINAL   PAIN 


145 


For  many  years  he  has  been  in  the  habit  of  taking  from  twelve  to 
twenty  glasses  of  beer  and  three  to  five  glasses  of  whisky  daily.  He 
chews  a  live-cent  plug  of  tobacco  a  day,  and  smokes  three  or  four  pipefuls 
besides.  He  has  always  been  very  well  and  strong  until  five  months 
ago,  when  he  began  to  have  dull  pain  in  the  al^domen,  not  definitely 
localized,  but  more  marked  in  the  lower  half.  This  ^vas  accompanied 
by  distress  and  flatulence  after  meals,  and  frequent  vomiting  imme- 
diately after  the  taking  of  food.  The  vomitus  is  bitter,  yellow-green, 
never  bloody.  His  appetite  is  poor,  his  bowels  consti{)ated,  and  he  has 
been  short  of  breath  for  the  past  four  weeks.  For  the  past  two  weeks 
he  has  had  to  pass  his  urine  twice  each  night.  Two  years  ago  he  weighed 
155  pounds;  to-day  he  weighs  121. 

On  physical  examination  the  skin  is  dry  and  satiny.  There  is  a 
marked  alcoholic  odor  on  the  breath.  The  arteries  are  all  palpable, 
and  there  is  a  lateral  pulsation  in  the  brachials.  The  chest  and  ab- 
domen showed  nothing  abnormal. 

Examination  of  the  blood  showed  red  cells,  2,030,000;  white  cells, 
7200;  hemoglobin,  25  per  cent.  The  stained  specimen  showed  achromia, 
slight  poikilocytosis,  many  off-colored  cells,  no  nucleated  red  cells. 

The  urine  was  negative.  After  a  test-meal  the  stomach-contents 
showed  no  free  hydrochloric  acid.  The  gastric  capacity  was  23  ounces. 
His  stools  were  brownish-black,  with  a  well-marked  reaction  to  guaiac. 
Rectal  examination  was  negative.     The  prostate  was  not  enlarged. 

Discussion. — -The  excesses  in  alcohol  and  tobacco  above  described 
would  naturally  lead  one  to  suspect  cirrhosis  of  the  liver.  The  long- 
continued  gastric  symptoms,  as  well  as  all  the  minor  complaints,  could 
be  thus  explained.  The  guaiac  reaction  in  the  feces  might  be  the  result 
of  blood  poured  out  from  dilated  veins  in  the  esoj)hagus  or  stomach. 
Against  this  supposition,  however,  is  the  extreme  degree  of  anemia,  with- 
out any  history  of  severe  hemorrhage.  Even  if  the  blood  were  dis- 
charged by  rectum,  the  patient  would  ])robably  be  made  aware  ])y  faint- 
ness,  weakness,  and  thirst,  of  the  loss  of  an  amount  of  blood  sufficient 
to  ex])lain  the  ])resent  anemia.  It  is  unusual,  furthermore,  that  a  cir- 
rhosis disables  the  |)atient  and  produces  such  marked  symptoms  as  are 
here  present,  without  manifesting  itself  by  any  change  in  the  size  of  the 
liver  or  by  the  accumulation  of  ascites. 

Whenever  a  patient  past  forty  years  of  age,  and  pre\i(nisly  iwc 
from  stomach  trouble,  begins  to  haxe  any  sort  of  gastric  {Jiscomfcii. 
se\ere  or  mild,  gastric  carcinoma  should  be  considered.  Tliis  diagno- 
sis would  explain  all  the  symj)tonis  in  this  case,  including  the  anemia. 
It  is  remarkable,  liowever,  that  there  should  be  no  more  de'inite  e\i(K'nce 

lu 


X46  DIFFERENTIAL  DIAGNOSIS 

of  gastric  stasis,  no  food  in  the  vomitus  or  in  the  stomach-washings. 
If  cancer  is  present,  it  is  probably  not  at  the  pylorus — its  usual  seat. 

So  extreme  a  degree  of  anemia,  associated  with  gastric  symptoms 
and  achylia  gastrica,  brings  the  thought  of  pernicious  anemia  to  mind. 
The  blood,  however,  is  very  uncharacteristic,  and  is,  indeed,  tyi:)ical 
of  secondary  anemia. 

On  the  whole,  gastric  cancer  is  the  most  probable  diagnosis. 

Outcome. — On  the  morning  of  the  twenty-seventh  of  August  the 
right  middle  finger  was  blanched  and  cold  up  to  the  knuckle-joint. 
Examination  of  the  patient  in  the  warm  bath  showed  a  sharp  edge  in  the 
region  of  the  liver,  descending  with  respiration.     (See  Fig.  27.) 

On  the  third  of  September  the  abdomen  was  opened,  and  an  inoper- 
able cancer  of  the  anterior  stomach-wall  found.  The  mass  thought  to 
be  liver  before  operation  proved  to  be  part  of  the  gastric  tumor. 

Diagnosis. — Cancer  of  the  stomach. 

Case  61 

An  Italian  shoemaker  of  thirty-two  has  complained  for  a  year  of 
general  bellyache  with  diarrhea,  at  times  bloody.  Much  intestinal 
noise.  Has  lost  28  pounds  in  two  months.  For  the  past  week  he  has 
been  costive. 

Examination  was  negative,  excepting  for  a  palpable  spleen  and  a 
hemoglobin  of  65  per  cent.  During  his  fortnight  under  observation 
(September  1-14,  1904)  he  had  no  fever,  no  diarrhea,  and  gained  eight 
pounds.  He  had  slight  abdominal  pain,  especially  at  night.  There  was 
slight  tenderness  in  both  iliac  fossae.  Colitis,  possibly  tuberculous,  was 
the  diagnosis  in  the  out-patient  department  and  in  the  wards. 

Next  spring  (May  22,  1905)  he  was  again  at  the  hospital.  His 
pain,  he  said,  had  never  ceased.  Constipation  has  been  obstinate 
and  is  getting  worse.  The  rumbling  noises  are  still  loud.  He  has 
lost  14  pounds  since  his  previous  entry. 

Slightly  above  the  region  of  the  cecum  is  a  firm,  regular  mass,  about 
the  size  and  shape  of  the  kidney,  freely  movable  in  all  directions,  dis- 
tinctly tender  on  pressure.  No  reaction  to  tuberculin  (two  large  doses). 
Stools  foul,  watery,  no  blood,  no  tubercle  bacilli,  some  mucus. 

Discussion. — In  \icw  of  the  information  which  came  to  light  when 
this  patient  entered  the  hos])ital  for  the  second  time,  there  are  only  two 
diseases  to  be  considered  as  at  all  likely  to  ])roduce  tliese  symptoms, 
viz.,  cancer  of  the  cecum  and  ])ericecal  tul^erculosis.  The  latter  is  made 
unlikely  l)y  tlie  negative  reaction  to  tul)erculin. 

The    interesting    question    remains:  could    the    cancer    which    now 


Fig.  27. — l)i;i;_;r:iin  of  llie  liiidiiiLis  in  Case  60.     Chief  com])iaints,  dull  ahdoniinal  pain, 

vomiling,  and  nalulcnce. 


GENERAL   ABDOMINAL    PAIN 


147 


shows  itself  at  the  cecum  have  been  suspected  in  1904?  Certainly  no 
positive  diagnosis  of  this  disease  could  have  been  made,  but  it  seems  to 
me  that  whenever  we  have  the  history  of  very  loud  and  marked  intestinal 
noise,  accompanied  by  pain  experienced  at  short  intervals  throughout  a 
year's  time,  we  ought  to  suspect  that  some  sort  of  disease  has  caused 
intestinal  stricture  with  muscular  hypertrophy  of  the  gut  behind  it.  It 
is  true  that  in  many  cases  of  diarrhea  from  colitis  intestinal  noise  is 
heard,  but  it  is  especially  in  the  acute  varieties  that  we  meet  with  this 
symptom.  In  cases  lasting  a  year  it  is  much  more  uncommon.  Again, 
a  good  many  women  are  troubled  by  intestinal  noise  at  the  time  of  the 
menstrual  period,  or  whenever  they  are  especially  nervous,  but  the  process 
is  never  so  continuous  as  in  the  present  case. 

Except  for  this  symj^tom,  the  diagnosis  of  chronic  colitis  was  certainly 
justifiable  in  1904.  The  case,  however,  reenforces  in  a  striking  way  the 
well-known  rule  that  in  all  long-standing  diarrheas  intestinal  obstruction 
should  be  suspected,  especially,  but  not  exclusively,  in  elderly  yieoj)le. 
It  is,  of  course,  a  very  familiar  fact  that  many  cases  of  cancer  of  the  sig- 
moid begin  with  diarrhea. 

Despite  such  warnings  as  are  given  us  by  a  case  like  this,  the  diag- 
nosis of  intestinal  cancer  is  often  entirely  impossible  with  our  ])resent 
methods  of  investigation.  There  is  good  reason  to  believe  that  it  is 
often  present  and  c[uite  latent  for  years.  The  symptoms  we  see  are 
merely  terminal.  For  example,  a  patient  whom  I  saw  in  1906  for  pain 
high  up  in  the  rectum,  accompanied  by  discharges  of  blood  and  mucus, 
had  been  troubled  by  severe  periodic  ])ains  with  considcral^le  consti])a- 
tion,  referred  to  appendicitis,  for  at  least  fifteen  years.  At  the  autopsy 
in  June,  1907,  cancer  of  the  sigmoid  was  found,  but  no  a])])endicitis. 
In  another  grou])  of  cases  the  patient  is  aware  of  the  ])resencc  of 
tumor  in  the  abdomen  for  three  or  four  years,  without  any  ])ain  or  dis- 
turbance of  the  bowels,  yet  the  tumor  turns  out  on  exploration  to  be 
cancerous.  Not  infrequently  ])ain  may  be  referred  to  the  ])it  of  the 
stomach,  and  so  closely  associated  with  ordinary  gastric  symptoms 
that  all  our  attention  is  drawn  in  that  direction. 

Outcome. — Dr.  Conant  diagnosed  tuberculous  rohtis  and  adxised 
operation, 

A  growth  the  si/e  of  an  orange  was  found  in  tlie  ri'cum  ladino 
carcinoma  by  microsco])ic  examination)  and  excised.  Discharged  wvW 
June  2_:5d. 

A  year  later  (June  5,  kjoO)  he  returned.  The  o])erati()n  liiu!  '/iwu 
relief  for  months,  and  he  had  gained  20  ])ounds.  but  of  late  i>ain  and 
bloodv  stools  ha\e  returned,  this  time  in  the  left  Iowit  ouadrant.  ^'diere 


148  DIFFERENTIAL  DIAGNOSIS 

there  is  a  mass  i  by  2]  inches,  and  tenderness.     Operation  showed 
inoperable   cancer   of   the   sigmoid.     Cecal   region   normal.     Inguinal 
colostomy.     Discharged  July  7,  1906,  to  out-patient  department. 
Diagnosis. — Recurrent  intestinal  cancer. 

Case  62 

A  boy  of  eleven  was  seen  September  28,  1903.  Since  his  third  year, 
when  he  had  malaria,  he  has  had  fleeting  pains  in  his  arms  and  legs, 
especially  at  night.     The  feet  often  show  toe-drop. 

For  three  months  he  has  been  troubled  with  attacks  of  bellyache, 
accompanied  often  by  chill  and  vomiting  and  by  an  increase  in  the 
troubles  in  his  arms  and  legs. 

Twice  he  has  had  tonic-clonic  convulsions. 

Discussion. — When  a  child  has  a  stomachache  in  summer,  it  would 
be  folly  to  conclude  that  malaria  is  the  cause;  but  it  is  equal  folly  not  to 
suspect  that  malaria  may  be  the  cause.  For  some  unknown  reason  the 
malarial  attacks  of  children  and  of  young  adults  are  much  more  likely 
to  Ijc  atypical  than  those  of  older  persons. 

(a)  Malaria  often  exists  in  children  without  producing  any  symptoms 
at  all,  and  is  demonstrated  only  by  blood  examination. 

(b)  In  many  cases  it  produces  only  a  recurrent  headache  and  list- 
lessness,  due,  in  fact,  to  a  rise  in  temperature  every  twenty-four  or  forty- 
eight  hours,  without  any  chill  ("dumb  ague"). 

{c)  Vomiting  recurring  at  regular  intervals,  daily  or  every  other  day, 
has  been  the  only  suggestion  of  malaria  in  some  of  my  cases  until  the 
blood  was  examined. 

(d)  An  intractable  diarrhea  is  sometimes  associated  with  a  malarial 
infection  of  the  blood,  and  promptly  cured  by  the  administration  of 
quinin. 

(e)  Abdominal  pain  of  the  type  exemplified  in  this  case  is  perhaps 
the  most  common  of  the  atypical  manifestations  of  malaria.  In  some 
cases  it  is  localized  in  the  right  iliac  fossa.  In  one  week's  ser\'ice  at  the 
Massachusetts  General  Hospital  three  patients  were  sent  in  to  be  operated 
upon  for  supposed  ap])endicitis.  All  of  them  had  malaria,  and  were 
promptly  cured  by  quinin.  These  have  been  referred  to  by  Dr.  James 
M.  Jackson,  in  his  article  published  in  tlie  Boston  Medical  and  Surgical 
Journal,  June  26,  1902.  I  have  already  referred,  in  the  discussion  of  a 
previous  case  (see  p.  121),  to  a  case  of  malaria  beginning  like  pneu- 
monia with  violent  thoracic  pain. 

(/)  In  adults  we  not  infrequently  see  cases  of  malaria  with  predom- 
inating cere})ral  symptoms,  such  as  acute  mania  or  coma. 


GENERAL  ABDOMINAL   PAIN 


149 


Now  if  malaria  can  assume  such  a  bewildering  variety  of  clinical 
aspects,  what  is  to  guide  us  toward  correct  diagnosis.  I  should  answer 
that  in  practically  all  these  atypical  forms  a  thorough  blood  examination 
should  be  suggested  by  the  presence  of  an  irregular  fe\er  and  the  low 
leukocyte  count.  Enlargement  of  the  spleen  and  the  firm,  painless  edge 
which  the  organ  presents  to  the  palpating  finger  are  generally  to  be  recog- 
nized in  these  cases,  and  should  also  ])ut  us  upon  our  guard  against 
malaria.  The  therapeutic  test  is  valuable,  but  should  not  be  abused  by 
continuing  to  pour  quinin  into  the  patient  at  the  rate  of  20  to  40  grains 
a  day  for  a  week  or  more.  This  is  not  a  therapeutic  test:  it  is  a  stuj)id 
blunder.  Two  or  three  days  is  enough  to  settle  the  matter  in  999  cases 
out  of  loco,  and  in  the  remaining  case  no  further  information  is  obtained 
by  prolonging  the  administration  of  quinin. 

Outcome. — The  blood  was  found  to  be  swarming  with  tertian  para- 
sites.    Wrist-drop  and  toe-drop.     Knee-jerks  absent. 

Diagnosis. — Tertian  malaria. 


Case  63 

A  woman  of  fifty,  a  lawyer's  clerk,  entered  the  hosj^tal  January  2, 
1906,  stating  that  she  had  had  many  attacks  similar  to  the  present  one, 
but  had  al\\ays  been  able  to  work.  Two  days  ago  she 
felt  some  abdominal  discomfort  in  the  afternoon.  Early 
yesterday  morning  she  awoke  with  a  sharp,  steady  pain, 
especially  in  the  right  side  of  the  abdomen,  but  not 
definitely  localized.  This  was  accompanied  l)y  disten- 
tion and  obstinate  constipation.  Last  night  the  pain 
was  felt  in  the  left  side.  She  has  vomited  several  times, 
and  has  slept  poorly  on  account  of  pain.  (For  tem- 
perature, see  chart.) 

The  abdomen  is  distended,  tympanitic,  and  generally 
tender;  white  cells,  4600;  urine,  1029;  a  very  slight 
trace  of  albumin;  many  fine,  granular  casts.  Pliysical 
examination  was  otlierwise  negative.  A  glycerin  enema 
and  liot-water  l)()ttle  to  the  al)domcn  ga\'e  her  some  relief, 
but  on  the  morning  of  the  fourth,  the  temperature 
continuing  to  rise,  though  the  white  cells  were  still  only 
4000,  she  was  o])erated  u])on. 

Discussion. — A    definite    diagnosis  was    iiupossibk- 
here,  luit  the  general  a])])earanre  of  the  ])ati(.!U  made  it 
clear  that  she  was  very  ill,  whik-  tin-  course  of  tiu'  s\m]itoms  wriit  on 
progressi\ely  from  bad  to  worse,      it   was    for   these    reasons    tliat    the 


h.irt 


15° 


DIFFERENTIAL   DIAGNOSIS 


abdomen  was  opened,  although  without  any  clear  notion  of  what  would 
be  found. 

Outcome. — Chronic  ulcerative  enteritis  and  colitis,  with  numerous 
strictures  and  di\erticula,  were  found.  One  of  these  diverticula,  which 
contained  an  orange-seed,  had  perforated  and  gave  rise  to  general 
peritonitis,  from  which  she  died.  At  autopsy  the  enteritis  seemed  to  be 
due  to  tuberculosis  or  syphilis. 

This  case  is  introduced  chiefly  to  show  how  short  and  how  slight  may 
be  the  symptoms  associated  with  a  fatal  general  peritonitis.  The  pain 
was  never  sharp  during  the  time  when  she  was  under  observation,  and 
there  was  no  muscular  spasm.  The  subnormal  leukocyte  count  was 
doubtless  due  to  the  virulence  of  the  process,  but  previous  to  the  opera- 
tion it  was  impossible  to  be  sure  of  this. 

It  is  probable  that  this  patient  had  previously  had  many  slow  and 
partial  perforations  of  the  gut,  which  were  protected  by  adhesions  so  that 
no  general  peritonitis  resulted.  In  a  normal  intestine  an  orange-seed 
does  no  harm;  only  in  the  presence  of  seN'ere  ulceration  and  thinning  of 
the  intestinal  wall,  such  as  was  present  here,  could  such  a  foreign  body 
be  dangerous. 

Diagnosis. — Perforative  colitis  and  general  peritonitis. 

Case  64 

A  woman  of  fifty-four  has  had  for  a  year  cramps  after  meals  in  various 
parts  of  the  abdomen.  The  pain  has  not  been  severe,  but  has  led  her 
to  cut  out  from  her  diet  one  food  after  another  in  search  of  relief,  until 
now  she  eats  very  little,  and  has  lost  45  pounds  during  the  year. 

Eight  months  ago  the  bowels  began  to  mo\-e  more  and  more  often, 
and  now  act  eight  to  ten  times  a  day,  with  blood  and  pain  on  defecation. 

On  examination  the  internal  viscera,  the  urine,  the  temperature, 
pulse,  and  resjjiration  are  normal.  Digital  examination  of  the  rectum 
shows  a  relaxed  external  sphincter,  with  ballooning  above  it.  The  red 
cells  are  1,792,000;  hemoglol)in,  25  per  cent.;  leukocytes,  12,400,  86 
per  cent,  of  which  are  polynuclear. 

Discussion. — Chronic  colitis  is  so  common  in  elderly  persons  that 
it  is  naturally  our  first  thought  in  this  case.  It  is  especially  frequent 
when  there  is  a  slight  degree  of  interstitial  change  in  the  kidneys,  as 
evidenced  by  high  blood-pressure,  with  or  without  characteristic  urinary 
changes.  This  possibility  certainly  cannot  l)e  excluded  by  any  of  the 
facts  so  far  given. 

Pernicious  anemia  produces  a  reduction  in  red  corpuscles  such  as  is 
here  present,   and  is  often  associated  with  a  chronic  diarrhea,  but  in 


GENERAL   ABDOMINAL   PAIN  151 

the  finer  points  revealed  by  blood  examination  the  picture  is  one  of 
secondary  anemia. 

Any  case  presenting  these  symptoms  demands  a  very  careful  examina- 
tion of  the  rectum  and  lower  sigmoid  by  means  of  a  speculum,  since 
cancer  of  this  part  of  the  gut  is  a  frequent  cause  of  all  the  symptoms 
here  presented. 

Outcome. — Through  a  rectal  speculum  with  an  adequate  light  a 
large  cauliflower  mass  could  be  seen  nearly  occluding  the  upper  part  of 
the  rectum.  From  it  there  was  a  foul  serosanguineous  discharge.  An 
excised  bit  proved  to  be  cancer. 

Diagnosis. — Cancer  of  the  rectum. 

Case  65 

An  active,  muscular  young  man  of  twenty-six,  a  machinist  by  trade, 
had  always  been  perfectly  well  until  three  years  ago,  when  he  had  an 
attack  of  acute  appendicitis  for  which  an  operation  was  performed. 
A  fn^e-inch  incision  was  necessary;  the  wound  was  drained  for  a  long 
time,  and  later  a  large  ventral  hernia  developed.  Thereafter  he  seemed 
perfectly  well  until  five  days  ago,  when  he  had  an  attack  of  acute  general- 
ized abdominal  pain  lasting  for  about  eighteen  hours,  and  accompanied 
l)y  constipation.  He  was  then  perfectly  well  for  the  two  succeeding 
days,  wlien  a  second  attack  of  pain  came  on,  accom])anied  by  nausea 
and  vomiting.  This  had  persisted  nearly  twenty-four  hours  when  he 
was  seen  in  consultation. 

When  examined,  the  head,  chest,  and  extremities  showed  nothing 
remarkable.  The  abdomen  was  slightly  tender  throughout,  and  there 
\vas  a  moderate  amount  of  s])asm  not  localized.  Attacks  of  colicky 
])ain,  now  here,  now  there,  but  for  the  most  part  in  the  uml^ilical  region, 
recurred  e\'ery  few  minutes.  There  was  no  1)ulging  at  the  seat  of  the 
scar,  and  no  ])alpal3le  mass  anywhere.  There  was  slight  dulness  in  the 
flanks,  which  shifted  with  change  of  position.  The  tcm])eraturc  was 
normal;  the  ])ulse  no  and  of  low  tension.  The  face  was  drawn  and 
showed  e\"i(lcnces  of  se\erepain;  indeed,  the  ])atient  looked  exceedingly 
ill.  The  Ijlood  and  urine  showed  nothing  a])n()rmal.  There  was  no 
lead-line  on  the  gums.  An  enema  ])rought  away  a  small  movement, 
normal  in  character. 

Discussion. — Intestinal  obstruction  and  general  ])eritonitis  are  ilie 
nifwi  likeh-  h\-])otheses.  Tliere  is  notliing  in  liis  occu])atioiM  nor  in  ilie 
examination  of  tlie  blood  and  the  gums  to  make  lea(k]ioisoninLr  ;!i  ;  H 
l»robal)le.  If  perforative  ])eritonitis  were  pri'sent.  there  would  be 
ai'it  to  be  more  tenderness  and  some  fe\"er.     ^'et  1  lia\'e  se\erat  tinie-  seen 


152  DIFFERENTIAL   DIAGNOSIS 

acute  virulent  peritonitis  demonstrated  without  any  fever  or  tenderness. 
We  have  no  evidence  pointing  to  any  source  for  peritonitis,  and  nothing 
to  connect  the  symptoms  with  the  stomach  or  the  gall-bladder,  while 
the  appendix  has  already  been  excluded  surgically.  What  can  we  argue 
from  the  presence  of  shifting  dulness  in  the  flanks?  In  the  absence  of 
diarrhea  there  is  every  reason  to  believe  that  this  sign  indicates  fluid  free 
in  the  peritoneal  cavity,  but  this  is  fully  as  common  in  cases  of  intestinal 
obstruction  as  in  general  perforative  peritonitis. 

Many  of  the  symptoms  here  present  could  be  explained  by  simple 
constipation.  Indeed,  on  paper  this  seems  quite  a  reasonable  diagnosis. 
In  the  living  patient,  however,  this  could  be  quite  readily  excluded  by 
the  obvious  severity  of  the  patient's  sufferings  and  of  the  prostration 
accompanying  them.  By  the  same  tokens  it  was  easily  possible  to  rule 
out  those  multiform  neuroses  which  are,  on  the  whole,  the  commonest 
cause  of  general  abdominal  pain. 

By  exclusion,  intestinal  obstruction  seems  the  most  probable  diag- 
nosis. 

Outcome. — The  abdomen  was  opened  at  once,  and  the  mesentery 
of  the  lower  ilium  was  found  to  be  tightly  twisted  on  itself,  the  twist 
leading  to  a  group  of  intestinal  coils  which  were  distended  and  dark 
purple  in  color.  There  were  many  adhesions  near  the  site  of  the  appen- 
dix, but  apparently  these  were  not  responsible  in  any  direct  way  for  the 
strangulation.  There  was  about  a  quart  of  bloody  serum  free  in  the 
abdomen. 

The  intestines  were  untwisted  and  returned  to  their  proper  position, 
the  wound  sewed  up,  and  the  patient  made  an  uneventful  recovery, 

This  case  illustrates  the  truth  of  the  rule  that  in  young  people  most 
cases  of  intestinal  obstruction  are  connected  in  some  way  with  the 
results  of  a  previous  peritonitis  or  operation,  while  in  old  people  the  great 
majority  of  cases  are  due  to  cancer.  For  some  unknown  reason  twists 
occur  much  more  frequently  in  those  whose  peritoneums  have  ])ecn 
damaged  by  a  previous  operation  or  inflammation,  even  when  no  con- 
stricting band  of  adhesions  can  be  found. 

Diagnosis. — Obstruction  of  the  intestine;  volvulus. 


GENERAL  ABDOMINAL   PAIN 


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CHAPTER    V 

EPIGASTRIC   PAIN 
Case  66 

An  Italian  laborer  of  forty  entered  the  hospital  November  22,  1906. 
For  sixteen  days  he  had  been  having  pain  at  the  "pit  of  the  stomach." 
The  pain  came  on  rather  suddenly,  and  had  since  been  dull  and  steady, 
at  times  interfering  with  sleep.  He  has  not  been  able  to  work  since  the 
onset  of  the  pain.  It  has  no  relation  to  food  or  posture.  There  are  no 
gastric  or  urinary  symptoms,  no  jaundice,  no  constipation,  and  no  loss 
of  weight.  The  patient  denies  venereal  disease,  and  has  never,  to  his 
knowledge,  been  sick  before. 

Physical  examination,  except  in  so  far  as  relates  to  the  abdomen, 
was  negati\"e.  There  a  hard,  apparently  nodular  mass  was  felt  just 
below  the  ensiform  cartilage  and  a  little  to  the  left  of  the  median  line. 
It  was  not  tender,  and  descended  readily  with  inspiration.  The  liver 
dulness  extended  as  high  as  the  fourth  interspace,  but  the  edge  was  not 
felt.  The  blood  and  urine  showed  nothing  abnormal.  The  capacity 
of  the  stomach  was  enlarged  to  72  ounces,  and  the  lower  1)ordcr  reached 
4 J  inches  below  the  navel;  the  upper  border,  i  inch  above  it.  Free  HCl 
was  absent.  The  total  acidity  was  0.12  per  cent.  There  v^ere  no 
organic  acids,  no  blood,  no  fasting  contents.  There  was  no  reaction  to 
guaiac  in  the  stools.  The  patient's  temperature  ranged,  for  the  most 
part,  about  99°  F.,  often  reaching  100°  F.  and  occasionally  101°  F.  His 
pulse  and  res})iration  were  within  normal  limits.  At  times  there  \vas 
considerable  tenderness  over  the  epigastric  mass. 

Discussion. — Tuberculous  peritonitis  is  rcmarkaljly  common  in  the 
newly  arrived  Italian  immigrant.  The  presence  of  fe\er  and  of  ab- 
dominal pain  without  fulminating  or  alarming  sym])toms  is  quite  sug- 
gesti\"e  of  tuberculous  peritonitis,  but  wc  have  no  evidence  either  of  free 
fluid  in  the  aljdomen  or  of  the  tenderness,  spasticity,  and  localized 
masses  which  are  necessary  for  the  diagnosis  of  tliis  disease  when  fluid 
is  absent. 

Some  of  the  gastric  signs  in  this  case  are  quite  consistent  with  gastric 
cancer,  but  against  this  are  the  sudden  onset,  the  absence  of  emaciation, 
stasis,  or  blood. 
1.-4 


Causes  of  Epigastric  Pa 


IN 


CONSTIPATION 

DIARRHEA  AND  ENTERITIS 

ACUTE  INDIGESTION 

APPENDICITIS 

NEUROSES 

LEAD-POISONING 

INTESTINAL  OBSTRUCTION 

TABES 

TABES  PERITONITIS  AND  TABES  MESENTERICA 


NO   ACCURATE   STATISTICS 
AVAILABLE. 
-   ONLY    THE    FIRST    THREE    ARE 
COMMON    AS   CAUSES  OF   EPI- 
GASTRIC   PAIN. 


1.  GASTROHEPATIC 

CONGESTION 
DUE    TO    C  I  R-  I- 
RHOSIS  OR  CAR 
DIAC  DISEASE 

2.  APPENDICITIS 

3.  PEPTIC  ULCER 

4.  GALL-STONES 

5.  HYPERCHLOR-  | 

HYDRIA'  I 

6.  GASTRIC  CANCER        ■ 

7.  PERICARDITIS  ■ 

8.  GASTRIC  NEUROSIS   ■ 

9.  PANCREATITIS  I 


10.  PYLORIC  I 

ADHESIONS  ' 

11.  ANGINA  ABDOMI-  ) 

NALIS  ( 


'  Many   of   the>e   case.-^    may   actually    he    ca^e^    of    I'cptic    ulcer.      <  >ni\ 
autojoy  can  deride. 


898 

350 
347 
329 

326 

133 
88 
72 

7 


•latM:.  or 


EPIGASTRIC    PAIN 


157 


The  induration  about  a  partially  perforated  gastric  ulcer  sometimes 
produces  a  mass  in  the  left  hypochondrium  similar  to  that  here  described. 
But  as  the  symptoms  seem  to  have  no  relation  to  food,  and  as  there  is 
no  tenderness  or  spasm  about  the  indurated  point,  there  seems  to  be 
no  good  reason  to  consider  this  possibility  seriously. 

The  tumor  is  on  the  wrong  side  for  gall-bladder  disease,  and  the 
absence  of  colic  and  jaundice  makes  it  unnecessary  to  look  further  in  this 
direction. 

Malignant  disease  of  the  liver  might  cause  such  a  fever  as  is  here 
described,  and  occasionally  arises  without  any  previous  or  coincident 
growth  in  the  stomach.  This  possibility  cannot  be  excluded,  especially 
as  the  liver  seems  to  be  enlarged  upward;  but  the  left  hypochondi ium 
is  a  very  unusual  place  for  a  hepatic  neoplasm. 

On  the  other  hand,  the  position  of  the  mass  here  described  corre- 
sponds with  the  point  at  which  hepatic  syphilis  most  often  shows  itself. 
This  diagnosis  would  explain  the  fever,  and  is  more  consistent  with  the 
history  and  with  the  good  nutrition  of  the  patient.  In  the  absence  of 
any  further  evidence,  however,  one  could  not  do  more  than  suspect 
syphilis.  Treatment  by  mercury  and  potassium  iodid  and  the  use  of  the 
Wasscrmann  test  are  indicated  as  a  means  to  a  more  certain  diagnosis. 

Outcome. — On  December  6th  the  abdomen  was  opened,  and  the 
liver  was  found  to  be  adherent  to  the  abdominal  wall  by  fine,  soft  ad- 
hesions. The  mass  felt  through  the  abdominal  wall  was  found  to  consist 
of  an  irregular,  boggy,  yellowish-white  elevation,  from  which  a  con- 
siderable amount  of  pus-like  material  was  removed  by  cautery. 

Microscopic  examination  showed  it  to  1)e  a  gumma.  The  patient 
left  the  hospital  on  December  29th  feeling  perfectly  well. 

Diagnosis. — Hepatic  gumma;  syphilis. 

Case  67 

A  Lithuanian  of  twenty-nine,  working  in  a  rubber  factory,  and 
never  consciously  sick  in  his  life  before,  entered  the  hospital  Ay)ril  10, 
1907.  Sometimes  he  takes  as  much  as  eight  beers  and  four  whiskies 
daily.  At  other  times  he  goes  without  alcohol  for  at  least  a  week. 
lM)r  two  weeks  he  had  been  hax'ing  severe  epigastric  ])ain,  with  loss  of 
ap])elile  and   obstinate  consti{)ation. 

The  patient  was  very  nervous,  trembling,  and  pale.  The  red  ci'lls 
were  2,750,000;  hemogk)bin,  65  per  cent.;  white  cells.  7200.  The 
stained  smear  showed  7(S  per  cent,  of  ])()lvnuclear  cells  and  \ery 
marked  stip])Hng  of  the  reds.  The  abdomen  was  tlat,  mcxleratel}'  stitl. 
and  slightly  tender.     The  retlexes  were  \erv  li\ely,  and  there  was  hyper- 


158  DIFFERENTIAL   DIAGNOSIS 

esthesia  of  the  feet.  The  aortic  second  sound  was  accentuated.  The 
urine  showed  a  very  slight  trace  of  albumin;  otherwise  it  was  negative, 
as  was  the  rest  of  the  physical  examination. 

Three  days  after  entrance  the  patient  became  maniacal  in  the  night 
and  had  to  be  restrained.  This  continued  for  six  days,  after  which  he 
became  sane.  His  temperature  was  frequently  above  99°  F.,  and  once 
reached  101.4°  F-     This  was  at  the  height  of  his  maniacal  attack. 

Discussion, — The  history,  the  maniacal  attack,  and  the  gastric 
symptoms  point  toward  alcoholism.  The  anemia,  however,  is  not 
thus  to  be  explained. 

Tuberculous  peritonitis  and  meningitis  are  suggested  by  the  com- 
bination of  a  spastic,  tender  abdominal  wall,  and  the  maniacal  attack 
accompanied  by  fever.  This  form  of  tuberculosis,  however,  rarely 
produces  anemia,  and  mania  is  \'ery  unlikely  in  it,  unless  other  cerebral 
symptoms  (lethargy,  coma,  squints,  headache,  or  vomiting)  are  also 
].)resent. 

Work  in  a  rubber  factory  often  ])roduces  a  stubborn  type  of  general 
debility,  but  it  does  not  lead,  so  far  as  I  know,  to  fever,  to  mania,  or  to 
anything  like  this  grave  anemia. 

Nephritis  must  be  considered.  It  would  explain  the  albuminuria, 
the  accentuated  aortic  second  sound,  and  the  mania;  but  a  nephritis 
which  had  lasted  long  enough  to  produce  such  an  anemia  would  almost 
certainly  produce  a  demonstrable  enlargement  of  the  heart  and  some 
other  uremic  manifestations,  such  as  headache,  vomiting,  or  hemor- 
rhages. 

Lead-poisoning  should  always  be  considered  in  a  case  presenting 
the  combination  of  anemia  and  cerebral  symptoms,  especially  if  the  red 
cells  contain  a  basophilic  granulation,  as  in  this  case.  Looked  at  from 
this  point  of  view,  all  the  symptoms  seem  to  fall  very  naturally  into  line — - 
lead  colic,  lead  anemia,  lead  nephritis,  lead  encephalopathy. 

Outcome. — The  treatment  consisted  at  the  beginning  of  glycerin 
enemata  and  magnesium  sulphate,  with  morphin  for  the  pain.  lodid 
of  potash,  10  grains,  was  given  three  times  a  day,  while  hot  a])i)lica- 
tions  and  turpentine  stupes  were  also  used  for  the  pain.  Chloroform 
anesthesia  was  once  needed  during  his  attack  of  mania.  Fifteen  grains 
of  trional  were  given  several  times  for  sleep. 

April  19th  the  red  cells  were  3,600,000,  and  no  stip]jling  was  found. 

By  the  twenty-third  of  Aj)ril  he  had  nearly  recovered  and  was  ready 
to  go  home.  It  \\as  subse(|uently  found  that  he  drank  water  which  came 
through  a  lead  ])i])e,  and  that  he  seldom  let  the  water  run  before  drinking 
in  the  morninir. 


EPIGASTRIC    PAIN 


T59 


In  connection  with  this  case  I  will  mention  briefly  a  patient  to  whom 
I  was  called  because  of  anemia  and  convulsive  attacks.  She  was  a  }'oung 
married  woman  with  a  baby  three  months  old.  She  lived  in  a  rural 
district,  and  did  no  work  outside  her  own  house.  Epilepsy  and  uremia 
were  the  diagnoses  previously  considered,  but  examination  showed 
that  she  and  every  other  member  of  the  household  except  the  bab}-  had 
a  well-marked  lead-line  on  the  gum  and  all  the  other  evidences  of  lead- 
poisoning.  After  gi^■ing  up  a  water-supply  hea\ily  impregnated  with 
lead,  this  patient  rapidly  recovered. 

Diagnosis. — Plumbism. 

Case  68 

A  Vjlacksmith  of  twenty-three  entered  the  hospital  November  24, 
1906,  with  a  negative  family  history  and  past  history  and  good  habits. 
He  had  been  complaining  for  three  weeks  of  c])igastric  jjain,  usually 
coming  on  about  eleven  o'clock  in  the  morning,  seeming  to  bear  no  rela- 
tion to  food — descri])ed  as  "pulling"  in  character,  and  relieved  by  lying 
down.  There  had  l)ccn  slight 'tenderness  in  the  ejjigastrium,  especially 
under  the  right  ribs.  The  bowels  had  been  very  constipated,  moving 
only  once  in  three  days.  Three  days  ago  he  began  to  vomit,  and  had 
done  so  once  or  twice  a  day  since.  The  vomitus  contained  no  blood 
or  food,  but  was  yellow  in  color.  His  ])ain  was  never  ])resent  when  he 
waked  in  the  morning;  it  was  sometimes  brought  on  ]\v  drinking  water. 
He  ai)peared  to  be  15  ])ounds  lighter  than  in  the  j^revious  June. 

Physical  examination  was  entirely  negative,  except  that  lum])s  Mere 
felt  in  the  sigmoid  region. 

Discussion. — It  does  not  seem  likely  that  a  Ijlacksmith  of  t\\enty- 
three  is  suffering  from  a  ])ure  neurosis,  and  he  is  at  an  age  when  cancer  of 
the  stomach  is  very  rare,  llie  ])ain  comes  at  a  time  when  the  stomach 
is  likely  to  l)c  em})ty,  and,  therefore,  suggests  hyperchlorlivdria  or  dud- 
denal  ulcer.  The  fact  that  his  vomitus  contains  no  food  goes  to  strengthen 
this  hy})othesis,  and  the  negative  ])hysical  examination  is  entirely  con- 
sistent with  it. 

Is  it  ])Ossible  that  the  lum])S  felt  in  the  sigmoid  region  may  be  due  to 
a  fecal  accumulation  ])ehind  a  stricture,  cancerous  or  of  othci-  origin? 
1  have  known  cancer  of  the  intestine  in  a  l)o\'  of  tv.ent}' one,  so  that  the 
youth  of  this  ])atient  does  not  exclude  that  ])ossibility,  and  the  NomitinL^ 
and  consti])ation  are  (|uite  consistent  with  it.  In  the  al>sence  of  more 
definite  symptoms,  however  (such  as  visible  ])eristalsis.  Mood  m  llie 
stools,  and  abdominal  distention),  there  seems  to  \)v.  notliing  further  to 
verifv  this  idea. 


l6o  DIFFERENTIAL  DIAGNOSIS 

May  not  the  symptoms  be  due  to  simple  constipation,  so  called? 
Whv  then  should  he  have  symptoms  just  now  and  not  previously? 

On  the  whole,  the  youth  of  the  patient  and  the  short  duration  of  the 
symptoms  make  cancer  and  constipation  less  likely  than  the  other  al- 
ternative above  mentioned,  l^ut  no  certainty  can  be  attained  on  the  basis 
of  the  facts  here  presented.  Only  by  the  therapeutic  test — the  results  of 
treating  the  patient  for  duodenal  ulcer  (a  treatment  identical,  in  its 
early  stages,  with  that  of  hyperchlorhydria) — can  greater  certainty  be 
obtained. 

Outcome. — After  castor  oil  by  mouth  and  enemata  of  oil,  large 
movements  followed.  Guaiac  test  negative.  Olive  oil  by  mouth  also 
relieved  him  very  much,  likewise  a  gastric  ulcer  diet.  In  five  days  he 
seemed  to  be  entirely  well. 

Diagnosis. — Constipation. 

Case  69 

A  chambermaid  of  twenty-two,  with  a  negative  previous  history 
and  family  history,  entered  the  hospital  March  2,  1907.  In  February, 
1906,  she  had  what  was  called  "grip,"  followed  by  abdominal  pain, 
weakness,  and  the  loss  of  10  pounds  in  weight.  The  pain  was  sudden 
and  nagging,  coming  sometimes  immediately  after  meals,  sometimes 
later,  never  lasting  long,  and  never  severe.  She  has  had  recurrences 
of  this  pain  at  intervals  ever  since.  Four  weeks  ago  the  pain  became 
more  troublesome,  and  was  accompanied  by  belching  and  constipation. 
It  did  not  always  remain  in  the  epigastrium,  but  might  shift  to  the  lower 
abdomen,  to  the  left  chest,  and  to  the  back.  It  seemed  to  be  produced 
especially  by  toast,  potatoes,  and  meat;  it  was  sometimes  relieved  by 
drinking  hot  water,  but  not  by  cooking-soda.  It  had  kept  her  awake 
during  the  past  two  nights.  She  also  complained  of  "palpitation  in  her 
stomach."  She  had  very  rarely  vomited.  At  the  present  time  her 
bowels  are  regular,  and  she  feels  fairly  well  except  for  weakness. 

On  physical  examination  it  was  noted  that  her  cheeks  were  red,  but 
her  lips  pale.  The  chest,  abdomen,  and  urine  showed  nothing  remark- 
able. Blood  examination  showed:  Red  cells,  4,976,000;  white  cells, 
5600;  hemoglobin,  60  ])er  cent.  The  stained  specimen  was  normal 
except  for  moderate  achromia.  The  patient  was  treated  l)y  a  careful 
diet. 

Discussion. — Lead-{)oisoning  is  always  one  of  the  possibilities 
when  a  patient  demonstrably  anemic  complains  of  abdominal  pain. 
Lead  may  be  excluded,  however,  in  my  opinion,  by  the  absence  of  baso- 
philic stippling  in  the  red  cells.      I  have  never  known  a  clear  case  of 


EPIGASTRIC   PAIN  l6l 

plumbism  without  stippling.  There  was  nothing  else,  moreover,  to 
favor  the  suspicion  of  lead-poisoning  in  this  patient. 

If  the  patient  were  somewhat  older,  the  history  would  be  quite  con- 
sistent with  gastric  cancer,  which  would  also  explain  the  anemia ;  but  as 
these  symptoms  have  lasted  a  year,  we  should  almost  certainly  find  more 
evidence  of  cancer  if  that  were  the  cause  of  the  patient's  sufferings. 

Chlorosis  is  generally  accompanied  by  constipation  and  hyper- 
chlorhydria,  which  appear  to  be  present  in  this  case.  The  age  and  the 
occupation  favor  this  diagnosis,  which  may  be  provisionally  accepted, 
subject  to  confirmation  by  the  results  of  treatment.  The  pain  in  this 
case  is  very  typical  of  that  most  often  associated  with  constipation, 
whether  or  not  the  latter  is  its  cause. 

Outcome. — The  bowels  were  regulated  by  cascara  and  enemata. 
She  was  given  lo  grains  of  Blaud's  pill  after  each  meal.  Recovery 
was  uneventful. 

Diagnosis. — Chlorosis. 

Case  70 

A  married  woman  of  thirty-five  entered  the  hospital  December  5, 
1906.  She  has  always  been  well,  but  subject  to  what  she  calls  bilious 
attacks.  She  was  operated  on  four  years  ago  for  strangulated  hernia. 
Since  then  she  has  had  a  great  deal  of  severe,  cramp-like  epigastric 
pain,  sometimes  relieved  by  a  movement  of  the  bowels.  On  December 
10,  1905,  the  catamenia  failed  to  appear,  and  she  had  vomiting  and 
headache.  In  January,  1906,  she  v/as  operated  on  for  extra-uterine 
pregnancy.  In  convalescence  she  was  troubled  1^}^  diarrhea  and  gaseous 
distention  of  the  bowels.  Later  on  she  was  obstinately  consti])atcd. 
She  felt  as  if  her  intestines  would  fall  out,  but  found  relief  by  holding 
them  up  with  her  hands.  Two  months  ago  she  woke  up  with  a  ^■iolent 
pain  in  her  right  hand.  The  next  morning  the  hand  was  swollen  up  so 
that  she  could  not  close  it.  This  trouljle  soon  ])assed  away,  l)ut  ever 
since  that  time,  she  says,  she  ne\'er  kne\v  when  a  shar]),  shooting  pain 
would  strike  her.  The  pains  were  felt  in  all  parts  of  the  l)ody,  and  lasted 
from  a  minute  to  foin  hours.  She  has  had  to  take  mor])hin  for  them  at 
times.  She  says  that  she  had  never  been  nervous  or  h^■sleric  ])efore. 
She  now  enters  the  hos])ital  expecting  an  operation  for  intestinal  obstrr.c- 
tion,  having  l)een  sent  in  Ijv  one  of  llie  \-isiling  surgeons  \\  ilh  a  diaLrnosis 
of  intestinal  o1)struction  of  mechanical  origin. 

Physical  examiiiation  showed  tliat  tlie  ])U[)ils  were  irregular  and  did 
not  react  to  light.  Knee-ierks  were  i)rcsent,  but  diiriinislu'd.  'J'lie 
ankle-jerk  wasal)sent;  otherwise  examination  of  the  re'lk-xes  was  iu-gati\'e. 


1 62  DIFFERENTIAL  DIAGNOSIS 

Sensation  and  coordination  appeared  to  be  perfect.  In  the  right  loin  a 
mass  was  felt  descending  below  the  ribs  on  deep  inspiration,  slightly 
tender. 

Physical  examination,  including  the  blood  and  urine,  was  otherwise 
negative. 

Discussion. — Certainly  a  very  complicated  case.  No  doubt  con- 
stipation accounts  for  a  part  of  the  symptoms,  but  the  pains  are  very 
wide-spread  and  unusually  intense  for  constipation.  Moreover,  there 
are  certain  facts  in  the  physical  examination  which  cannot  possibly  be 
thus  explained. 

Intestinal  obstruction  by  bands  or  adhesions  is  always  a  menace  in 
those  who  have  had  a  strangulated  hernia  and  an  operation  for  extra- 
uterine pregnancy;  but  for  the  same  reason  as  mentioned  in  the  last  para- 
graph, intestinal  obstruction  cannot  account  for  all  the  facts  in  this  case. 

Much  in  the  patient's  behavior  and  appearance,  and  something  in 
her  symptoms,  point  toward  a  neurosis,  but  this  would  not  account  for 
the  absence  of  ankle-jerks  and  pupillary  reactions. 

The  signs  just  mentioned  practically  assure  us  that  this  patient  has 
tabes  dorsalis.  The  only  important  question  remaining  is  whether  the 
tabes  explains  all  the  symptoms.  Certainly  the  pains  are  very  character- 
istic of  tfibes,  and  the  gastro-intestinal  symptoms  may  well  be  inter- 
preted as  "crises."  The  mass  in  the  loin  is  certainly  not  due  to  tabes, 
but  in  all  probability  does  not  represent  evidence  of  any  disease  what- 
ever, but  is  merely  a  sagging  kidney. 

On  the  whole,  it  seems  reasonable  to  believe  that  all  the  symptoms 
are  now  due  to  tabes.  At  any  rate,  the  patient  should  be  treated  on  that 
basis  for  the  present.  The  chief  lesson  of  the  case  is  the  necessity  for 
self-restraint  on  the  part  of  earnest  surgeons  when  the  patient's  pupils 
and  Achilles  tendons  fail  to  react. 

Outcome. — The  patient  remained  only  two  days  in  the  hospital, 
whither  she  had  come  reluctantly  and  under  the  impression  that  a 
second  operation  would  be  necessary.  When  it  was  decided  that  no 
operation  was  ad\'isable,  she  declared  that  she  felt  well  and  went  home  at 
once. 

Diagnosis. — Tabes  dorsalis. 

Case  71 

A  married  woman  of  forty-two,  of  negative  family  history  and  past 
history,  entered  the  hospital  December  i,  igo6.  On  January  28,  1906, 
she  broke  her  leg  and  was  confmcd  to  bed  for  eight  weeks,  during  which 
time  she  lost  her  appetite,  had  palpitation  of  the  heart,  a  grinding  pain 


EPIGASTRIC    PAIN 


163 


in  the  epigastrium,  and  a  feeling  as  if  there  were  strings  inside  her 
hitched  to  the  navel  and  to  the  backbone.  She  had  occasional  vomiting 
of  whitish  material.  She  was  given  various  medicaments  without  relief. 
In  July  she  began  to  walk  on  crutches,  but  her  symptoms  were  unrelieved. 
Her  appetite  was  poor,  and  she  lost  30  pounds  in  weight  between  Janu- 
ary and  December. 

Her  physical  examination  was  entirely  negative,  except  for  a  leuko- 
cytosis of  20,000.  The  gastric  capacity  was  27  ounces;  the  stomach 
considerably  prolapsed.  There  were  no  fasting  contents,  and  after  a 
test-meal  free  hydrochloric  acid  was  found  to  the  amount  of  0.23  per 
cent.  There  was  no  blood.  Three  days  later  the  white  cells  had  fallen 
to  10,000,  and  ranged  between  that  and  16,000  during  the  three  weeks  of 
her  stay  in  the  hospital.  At  no  time  was  there  anything  abnormal  about 
her  temperature,  pulse,  or  respiration. 

Discussion. — It  is  natural  to  fear  cancer  in  this  case,  for  gastric 
sjTnptoms  of  recent  origin  always  threaten  cancer  when  the  patient  is 
over  forty.  The  presence  of  abundant  free  hydrochloric  acid  in  the 
stomach-contents  by  no  means  excludes  cancer.  The  most  hopeful 
feature  in  this  regard  is  the  absence  of  tumor  or  stasis,  one  of  which 
would,  in  all  probability,  be  manifest  after  a  year  of  suffering. 

To  those  who  are  always  on  the  look-out  for  psychic  causes  in  gastro- 
intestinal disease,  the  fact  that  this  patient  had  no  stomach  trouble  until 
she  broke  her  leg  and  was  confined  to  bed,  offers  an  im])ortant  clue.  It 
should  lead  us  to  investigate  very  carefully  the  patient's  mental  condition. 

Outcome. — It  turned  out  on  careful  questioning  that  she  feared  she 
was  suffering  from  cancer.  She  was  greatly  encouraged  by  the  negative 
results  of  the  gastric  tests,  and  in  eighteen  days  gained  y]  pounds,  mostly 
as  a  result  of  forced  feeding,  with  laxatives  and  myrrh  pill,  one  or  two  at 
night,  aromatic  chalk  mixture,  sodium  bicarbonate  when  in  distress, 
and  a  quassia  cup  l)efore  meals.  She  was  also  relieved  by  10  grains 
of  sodium  bromid  after  meals,  and  on  two  or  three  occasions  had  trional 
at  night.     The  main  point,  however,  in  her  recovery,  was  forced  feeding. 

The  leukoc}tosis  is  not  cx])lained,  ])ut  must  be  listed  as  one  of  th(;se 
wild  and  untamed  facts  which  I  have  grown  to  ex])ect  as  a  normal 
element  in  every  well-studied  case. 

Diagnosis. — Gastric  neurosis. 

Cas3  72 

A  factory  hand  of  thirty-eight  entered  tlie  hospital  DfccmlxT  jo. 
1007.  Sc\-en  years  ago  he  began  to  suffer  from  ta]>c--w('rni.  nt  \\hich 
large  segments  were  passed  until  three  years  ago,  w  hen  the  \\  liole  worm 


164 


DIFFERENTIAL  DIAGNOSIS 


was  removed.  During  this  time  he  had  attacks  of  epigastric  pain  and 
vomiting,  often  associated  with  jaundice.  His  family  history  and  habits 
are  good.  Eight  days  ago  he  was  again  seized  with  pain  in  the  epi- 
gastrium, rehevcd  by  vomiting.  An  hour  later  the  pain  returned  and  he 
vomited  again.  This  happened  five  times  that  day.  The  next  day  he 
kept  quiet  and  had  no  pain  or  vomiting.  On  the  third  day  he  went  to 
work,  and  the  pain  and  vomiting  recurred.  On  the  fourth  day  he  was 
quiet  and  felt  well.  On  the  fifth  day  he  again  worked,  and  again  had 
pain  and  vomiting.  For  the  past  three  days  he  has  not  worked  and  has 
felt  well.  This  association  of  pain  with  work  has  been  present  in  all  his 
past  attacks.  He  has  never  had  pain  at  night,  on  Sundays,  or  on  holi- 
days; and  during  the  time  that  he  has  had  these  attacks  he  has  changed 
his  work  three  times.  His  pain  bears  no  special  relation  to  the  time  or 
kind  of  food.  The  vomitus  consists  of  small  amounts  of  greenish  mater- 
ial and  saliva.  He  has  never  seen  food  or  blood  either  in  the  vomitus 
or  in  his  stools.  During  the  attacks  his  appetite  is  poor  and  his  bowels 
constipated.  He  states  that  he  has  been  considerably  jaundiced  during 
this  last  attack.     He  has  lost  five  pounds  in  the  course  of  the  last  year. 

On  physical  examination  no  jaundice  is  found.  Many  teeth  are 
missing;  the  rest  are  in  fair  condition.  There  is  a  systolic  murmur 
at  the  apex,  not  transmitted.  The  heart-apex  is  in  the  fifth  interspace, 
inside  the  nii)ple-line.  The  aortic  second  sound  is  louder  than  the 
pulmonic  second  sound.  The  tension  of  the  pulse  is  apparently  high, 
the  lungs  normal.  The  abdomen  is  level,  slightly  rigid,  tympanitic 
throughout,  and  very  slightly  tender  on  pressure  in  the  epigastrium. 
There  are  slight  dulness  and  resistance  in  the  region  of  the  gall-bladder, 
but  no  jaundice.  The  liver  is  not  felt.  Physical  examination,  includ- 
ing the  blood  and  urine,  is  otherwise  normal. 

Discussion. — The  tape- worm  is  o])viously  "a  blind."  It  is  very 
unlikely  that  the  epigastric  pain  and  vomiting  from  ^^•hich  the  patient 
suffered  from  igoo  to  1904  had  any  real  connection  with  the  tape-worm. 
It  is  perhaps  worth  mentioning  here  tliat  practically  all  the  sym]:)toms 
traditionally  associated  with  tape- worm  arc  nn'thical.  In  the  vast 
majority  of  cases  tape-worm  produces  no  svir,j)toms  ^\•hatc^■er. 

Since  the  death  and  burial  of  "gastralgia,"  that  ancient  foe  of  clear 
diagnosis  and  helpful  treatment,  such  pain  as  this  patient  suffered  has 
been  shown  to  ])e  generally  due  to  one  of  two  causes — duodenal  ulcer  or 
gall-stones.  Since  the  attacks  l-.a\'e  apj>arently  l)ecn  iissociated  A\itli 
jaundice,  our  first  thought  is  gall-stones,  l)ut  on  a  closer  study  of  tlie 
case  we  find  that  he  has  now  no  jaundice,  although  he  now  considers 
himself  as  yellow  as  in  the  ])re\'ious  attacks.     This  makes  us  doubt 


EPIGASTRIC   PAIN 


165 


whether  he  really  was  ever  jaundiced.  I  have  many  times  found  reason 
to  discount  patient's  own  statements  in  this  matter.  Patients  and  their 
friends  often  use  the  word  "jaundice"  to  denote  nothing  more  defmite 
than  a  sallow  complexion.  To  the  consideration  of  duodenal  ulcer  I 
shall  return  later. 

Aneurysm  or  angina  abdominalis  is  suggested  by  the  fact  that  the 
pain  is  increased  by  exertion  and  the  pulse  tension  high.  On  the  other 
hand,  a  pain  which  produces  and  is  relieved  by  vomiting  is  rarely  due  to 
either  of  the  causes  just  mentioned.  The  physical  examination  shows 
no  evidence  of  aneurysm. 

Is  it  likely  that  the  lack  of  a  good  set  of  teeth  explains  some  or  all  of 
this  patient's  symptoms?  It  does  not  seem  to  me  so.  Despite  the  many 
positive  statements  regarding  the  close  association  of  digesti^•e  troubles 
and  poor  or  deficient  teeth,  I  have  never  seen  any  clinical  evidence 
which  would  enable  us  to  say  more  than  "perhaps,"  so  extraordinarily 
common  is  it  to  examine  people  who  have  li\ed  their  lives  quite  free  from 
digestive  troubles,  though  only  one  or  two  blackened  fangs  remain  in  each 
jaw.  I  by  no  means  deny  the  possiljility  that  malnutrition  or  poor  diges- 
tion may  in  certain  cases  be  due  to  defective  teeth,  but  I  think  we  need 
a  great  deal  more  definite  study  and  evidence  before  we  shall  have 
justification  for  the  positive  statements  and  the  expensive  municipal 
crusades  that  are  no^v  so  rife. 

A  definite  diagnosis  in  this  case  would  be  easier  if  we  knew — (a) 
\\'hcthcr  there  is  blood  in  the  stools  and  (b)  whether  hyperchlorhydria 
is  present.  Even  in  the  al)sence,  however,  of  these  data  I  think  the 
diagnosis  of  duodenal  ulcer  is  justifia])lc.  Between  this  disease  and  the 
hy])erchlorhydria  which  leads  to  it  diagnosis  is  not  always  possible,  as 
will  be  excm])lificd  in  a  sul)sequent  case.  The  absence  of  any  tem- 
peramental or  occupational  cause  for  the  worry  and  irritability  so  often 
associated  with  hyperchlorhydria  makes  me  incline,  on  the  whole, 
toward  ulcer. 

Outcome. — On  January  t,  too8.  tlie  abdomen  was  opened.  The 
galM)ladder  and  ducts  were  found  to  1)e  normal,  but  a  small  duodenal 
ulcer  was  present.     No  aneurysm.     Hie  patient  made  a  good  reco\ery. 

Diagnosis. — Duodenal  ulcer. 

Case  73 

A  married  woman  of  forty  se\'en,  \\\\h  negati\c  family  hist(M-\'  v.ud 
good  liabits,  entered  the  liospital  December  2t.  1007.  She  s1;i1t'(l  tlal 
for  eiuhteen  years  she  lias  had  abdfMiiinal  erauii)s  e\erv  three  or  tour 
UKHitlis,  but  lliat  for  tin;  last  two  weeks  tliese  lKi\e  eonie  nuich   ir.ore 


1 66  DIFFERENTIAL  DIAGNOSIS 

often — seven  times  in  two  weeks.  The  pain  starts  in  the  epigastrium 
very  suddenly  and  without  known  cause,  without  relation  to  food, 
to  menstruation,  or  to  the  time  of  day.  It  radiates  to  the  right  flank, 
lasts  about  three  hours,  and  often  wakes  her  from  sleep.  It  is  usually 
accompanied  by  vomiting  of  food  or  brownish  liquid.  There  is  no  his- 
tory of  jaundice,  and  between  attacks  she  feels  perfectly  well,  although 
the  pain  is  so  severe  as  to  require  morphin.  Her  bowels  are  regular, 
her  urination  normal,  although  for  the  last  three  days  she  has  passed  less 
urine  than  usual.     She  thinks  she  has  lost  a  great  deal  of  weight. 

Physical  examination  is  negative,  except  for  considerable  epigastric 
tenderness.  The  white  cells  number  15,800;  the  stained  smear  negative. 
The  urine  contains  a  slight  trace  of  albumin;  gravity,  1030;  a  few  hyaline 
and  granular  casts. 

Discussion. — Such  symptoms  might  be  due  to  constipation,  but  her 
negative  statement  upon  this  point  was  confirmed  by  our  observation  in 
the  hospital.  The  history  is  also  suggestive  of  lead-poisoning,  except 
for  its  extreme  duration,  but  the  condition  of  the  blood  and  of  the  gums 
enables  us  to  rule  this  out. 

The  negative  physical  examination,  which  included  tests  of  the 
pupillary  and  other  important  reflexes,  makes  tabes  with  gastric  crisis 
out  of  the  question.  The  regularity  of  the  bowels  and  the  long  dura- 
tion of  symptoms  render  chronic  intestinal  obstruction  (cancer)  very 
unlikely. 

Gastric  cancer  is  always  to  be  feared  at  the  age  of  forty-seven  when 
the  patient  has  vomited  a  brownish  liquid  at  frequent  intervals,  has  had  a 
great  deal  of  epigastric  pain,  and  is  believed  to  have  lost  a  great  deal  of 
weight.  By  the  use  of  the  stomach-tube  we  were  able  to  establish  the 
fact  that  there  were  no  gastric  stasis  and  no  blood  in  the  stomach-con- 
tents or  in  the  vomitus.  The  size  of  the  stomach  was  normal,  and  no 
tumor  palpable. 

Duodenal  ulcer  often  gives  a  history  of  very  prolonged  suffering, 
similar  to  that  in  this  case,  and  there  is  nothing  in  the  history  to  exclude 
it.  Even  the  fact  that  blood  was  absent  from  the  vomitus,  the  artificially 
abstracted  gastric  contents,  and  the  feces  by  no  means  excludes  ulcer. 
The  radiation  of  the  pain,  however,  its  sudden  onset  and  its  sudden 
relief  by  morphin,  are  less  characteristic  of  duodenal  ulcer  than  of  the 
disease  next  to  be  considered.  We  note  also  the  al^sence  of  any  relation 
between  the  pain  and  the  digestive  activities. 

Gall-stones  might  explain  all  the  symptoms  in  the  case,  although  the 
diagnosis  is  not  forced  upon  our  notice,  as  it  would  be  were  jaundice 
present.     We  are  no  longer  surprised,  however,  to  find  gall-stones  in  the 


EPIGASTRIC    PAIN 


167 


absence  of  jaundice,  and,  on  the  whole,  no  other  diagnosis  seems  as 
likely.  The  negative  physical  examination  does  not  militate  at  all 
against  this  idea,  nor  does  the  condition  of  the  urine  incline  us  to  change 
our  minds,  though  it  is  not  at  all  obvious  why  the  albumin  and  casts  are 
present. 

Outcome. — On  December  26,  1907,  the  abdomen  was  opened  and 
15  large  stones  were  found  in  the  gall-bladder.  The  patient  made  a 
good  reco\ery. 

Diagnosis. — Gall-stones. 

Case  74 

A  tailor  of  forty-nine  with  a  good  family  history  and  good  habits 
entered  the  hospital  on  June  15,  1907.  For  the  last  eighteen  years  he 
has  had  occasional  spells  of  dull  epigastric  pain  coming  on  in  the  after- 
noon for  a  month  or  so.  These  attacks  had  never  troubled  him  much, 
and  were  often  absent  for  a  month  at  a  time;  but  for  the  last  ten  years 
they  have  become  more  frequent,  and  the  pain  has  appeared  in  the 
morning,  as  well  as  in  the  afternoon,  accompanied  by  a  feeling  of  weight 
in  the  abdomen,  but  rarely  by  vomiting.  About  a  year  ago  the  pain 
began  to  come  regularly  between  10  and  12  in  the  morning,  and  between 
4  and  6  in  the  afternoon,  except  during  the  periods  when  he  was  under 
treatment.  The  pain  is  now  sharp,  and  radiates  sometimes  from  the 
epigastrium  to  the  back,  rarely  to  the  left  hypochondrium.  It  is  partly 
relieved  by  eating,  and  wholly  by  cooking-soda,  but  never  by  pressure. 
He  frequently  l^elches  gas. 

Two  months  ago,  after  a  day  during  which  he  had  been  constantly 
regurgitating  sour  fluid,  he  vomited  at  one  time  almost  three  quarts  of 
sour,  foaming  yellow  fluid,  with  great  relief.  Two  weeks  ago  he  vomited 
a  similar  quantity,  and  at  the  end  of  it  was  a  little  chocolate-colored 
stuff.  He  thinks  he  has  lost  20  pounds  in  the  last  six  months,  yet  he 
worked  until  May  29th  and  until  very  recently  felt  as  strong  as  cNcr, 
and  has  eaten  and  sle])t  well. 

Physical  examination  was  negative,  cxccjit  that  the  stomach  ca])acity 
was  74  ounces,  the  organ  extending  three  inches  below  the  navel  and 
showing  visible  peristalsis. 

Discussion. — Here  is  a  historv  nearlv  tvpical  of  duodenal  ulcer. 
I  ha\e  gisen  it  here  to  prove  that  in  some  such  cases  no  ulcer  is  demon- 
strable at  operation.  One  of  the  wisest  clinicians  of  my  acciuainlance 
recently  said  in  a  personal  letter:  "In  my  ex])erience  '  hyperchlorh\(h-!a  ' 
generally  spells  duodenal  ulcer."  T  agree  with  this  statement  if  it  is 
taken  literallv— that  is,  if  we  distinguish  "generallv"   from   "always." 


1 68  DIFFERENTIAL  DIAGNOSIS 

My  object  at  the  present  time  is  to  exemplify  one  of  the  weak  points  in 
clinical  diagnosis — our  inability,  namely,  clearly  to  distinguish  the  two 
diseases  above  referred  to.  Had  we  known  at  the  outset  that  this  patient 
was  an  alcoholic,  the  balance  might  have  inclined  a  little  more  toward 
hyperchlorhydria,  as  this  trouble  is  not  infrequently  associated  with 
alcoholism.  But  still  we  should  have  been  wandering  in  the  region  of 
probabilities. 

Outcome. — Operation  on  the  ninth  of  July  show^ed  no  dilatation, 
ulceration,  or  scar  formation  anywhere  in  the  stomach  or  duodenum. 
The  pyloric  ring  was  of  good  size.  The  patient  made  a  good  recovery, 
and  on  July  28,  1908,  reports  that  he  had  had  similar  attacks  of  pain, 
but  less  severe.  He  now  admits  that  at  times  he  drinks  liquor  freely, 
but  thinks  that  these  sprees  have  no  relation  to  his  gastric  attacks. 

Diagnosis. — Hyperchlorhydria  (alcoholism?) . 

Case  75 

A  farmer  of  forty-six,  with  a  negative  family  history  and  good  habits, 
entered  the  hospital  February  19,  1907.  For  the  past  two  years  he  has 
had  many  severe  attacks  of  epigastric  pain,  coming  without  apparent 
cause,  and  relieved  about  once  a  month  by  vomiting.  For  the  past  two 
weeks  the  pain  has  increased  in  severity.  He  localizes  it  accurately 
just  below  the  ensiform  cartilage,  and  describes  it  as  sharp,  increased 
by  coughing,  by  exertion,  or  by  a  meal  containing  pork,  eggs,  or  veal. 
It  is  usually  worse  at  night,  especially  just  after  he  goes  to  bed.  It  is 
somewhat  relieved  by  hot- water  bottles,  but  it  generally  keeps  him  awake 
most  of  the  night. 

Physical  examination  shows  the  heart's  impulse  two  inches  outside 
the  nipple-line  in  the  fifth  space.  There  is  a  presystolic  thrill  and 
murmur  at  the  apex,  ending  in  a  sharp  first  sound.  A  short  systolic 
murmur  is  also  heard  at  the  apex.  Both  murmurs  are  transmitted  to 
the  axilla.  The  pulmonic  second  sound  is  very  difficult  to  hear.  At 
the  base  of  the  heart  a  soft  systolic  thrill  can  be  felt  in  the  aortic  area, 
and  a  high-pitched  diastolic  murmur  heard  under  the  sternum  at  the 
level  of  the  third  rib  and  above  this  point,  together  with  a  soft  systolic 
murmur,  which  is  audible  throughout  tlie  precordia.  No  second  sound 
can  be  heard  in  the  aortic  region.  The  pulse  is  of  the  plateau  type; 
the  arteries  arc  tortuous  and  thickened.  There  is  a  lateral  excursion 
of  the  brachials.  Blood-pressure,  195.  The  edge  of  the  liver  is  felt  on 
inspiration,  and  there  is  moderate  tenderness,  sharply  localized  below 
the  ensiform  cartilage,  and  accompanied  l\v  muscular  spasm. 

Discussion. — In  this  case,  as  in  most  of  those  ])receding  and  follow- 


EPIGASTRIC   PAIN 


169 


ing  it,  the  pain  is  worse  at  night.  This  symptom  has  often  been  referred 
to  as  characteristic  of  gall-stone  pain  or  duodenal  ulcer,  and  there  are 
other  features  in  the  case  consistent  with  one  of  those  two  diagnoses, 
but  it  is  of  crucial  importance  in  the  study  of  this  case  to  note  that  the 
pain  is  increased  by  exertion  and  by  coughing.  This  is  not  usually 
the  case  with  duodenal  ulcer  or  gall-stones,  although  inflammatory 
adhesions  may  be  so  situated  that  muscular  action  stretches  them  pain- 
fully. 

The  presence  of  the  well-marked  heart  lesions  (aortic  stenosis  and 
regurgitation),  and  especially  of  the  high  blood-pressure,  makes  us 
suspect  any  pain  of  being  connected  with  the  circulatory  system.  The 
relation  to  exertion  is  very  characteristic  of  angina  pectoris.  Does  pain 
of  this  type  ever  occur  as  low  as  the  epigastrium?  It  certainlv  does, 
although  the  term  "angina  abdominalis"  is  perhaps  more  appropriate. 
I  have  seen  a  great  many  cases  of  this  type  treated  quite  unsuccessfully 
by  stomach  specialists  without  regard  to  the  circulatory  condition. 
To  get  further  clearness  on  the  diagnosis,  one  would  need  to  obse^^•e 
carefully  the  effect  of  rest  and  of  nitroglycerin.  Certainly  no  t^'pe  of 
stomach  or  gall-bladder  trouble  is  relieved  by  nitroglycerin. 

Outcome. — A  few  days'  observation  in  the  hospital  ward  demon- 
strated the  truth  of  our  suspicions:  rest  rendered  the  attacks  less  fre- 
quent, and  those  which  occurred  were  promptly  relieved  by  nitroglycerin. 

Diagnosis. — Angina  pectoris  (low). 

Case  76 

A  salesman  of  forty-nine  came  to  the  hospital  on  December  10,  1907, 
complaining  of  pain,  constipation,  and  vomiting.  He  is  in  the  haljit  of 
taking  several  drinks  of  whisky  a  day,  but  has  never  been  sick  until  the 
present  illness,  and  his  family  history  is  good.  For  five  weeks  he  has 
suffered  from  abdominal  i)ain.  The  pain  began  at  a  time  when  he  \\as 
"not  feeling  well,"  and  had  stopj^ed  work  for  a  few  days.  It  is  in  the 
epigastrium,  worse  at  night,  relieved  by  eating,  and  accompanied  by 
much  wind  and  belching.  It  usually  l^egins  al)out  4  P.  m.,  and  reaches 
its  maximum  severity  l)et\veen  11  P.  m.  and  4  A.  m.,  after  which  it  sul)- 
sides.  Of  late  it  has  come  every  night.  He  often  vomits  with  tlic  ])ain, 
and  last  night  did  so  three  times.  lie  lias  small  mo\ements  of  the 
bowels  every  second  or  third  day.  Two  montlis  ago  he  weiglxd  160 
pounds.     Now  he  weiglis  i,:;6  ])ounds. 

Physical  examination,  including  the  urine,  is  negatixe.  X<>  lead- 
line is  to  be  seen.  Tlie  leukocytes  nunil)er  10,400;  hemouloMn.  ()0 
per  cent.     In  the  differential  count  the  polynucK'ar  cells  are  So  ])er  ci'ut.; 


170  DIFFERENTIAL  DIAGNOSIS 

lymphocytes,  18  per  cent. ;  eosinophiles,  2  per  cent.  There  is  very  marked 
stipphng  and  abnormal  staining  of  many  red  cells. 

Three  days  later  the  urine  was  found  to  contain  a  trace  of  albumin, 
with  numerous  hyaline,  finely  and  coarsely  granular  casts,  many  with 
cells  adherent. 

Discussion. — Our  first  impression  is  naturally  that  "rum  done  it," 
but  on  second  thought  there  seems  no  special  reason  why  he  should 
suddenly  begin  to  suffer  at  this  time  as  the  result  of  so  long  continued 
a  habit. 

The  fact  that  his  bowels  are  so  constipated  raises  the  question 
whether  this  trouble  may  not  account  for  all  his  symptoms,  whether  it 
be  of  the  ordinary  functional  type  or  dependent  upon  a  stricture  (malig- 
nant?). But,  as  before,  the  question  arises,  why  should  he  suddenly 
begin  to  suffer  from  constipation  at  the  age  of  forty-nine?  The  func- 
tional types  of  the  affection  usually  make  their  appearance  long  before 
that  age.  Only  some  special  aberration  in  diet  or  some  great  nervous 
strain  would  account  for  the  sudden  appearance  of  functional  constipa- 
tion in  a  man  of  this  age. 

It  is  possible,  of  course,  as  I  have  previously  stated,  that  cancer  of 
the  bowel  may  exist  for  months  or  even  years  without  manifesting  its 
presence  by  any  symptoms,  but  when  we  look  over  the  history  and  ex- 
amine the  patient  with  this  possibility  in  mind,  there  seems  to  be  nothing 
to  support  it,  although  the  loss  of  weight  is  suggestive. 

A  pain  relieved  by  eating  often  occurs  in  connection  with  hyperchlor- 
hydria  or  peptic  ulcer,  and  there  is  nothing  in  the  case  absolutely  to 
exclude  these  affections,  which,  like  cholelithiasis,  must  always  remain 
in  the  background  of  our  minds  when  paroxysmal  epigastric  pain  is  the 
presenting  symptom. 

Before  making  any  further  investigation  or  following  up  any  other 
clue,  we  should  test  the  possibilities  suggested  by  the  presence  of  marked 
stippling  in  the  stained  red  corpuscles  despite  the  absence  of  anemia. 
Although  no  lead  line  is  seen  and  nothing  in  the  patient's  occupation 
suggests  plumbism,  this  blood  lesion  is  so  characteristic  that  every 
effort  should  be  made  to  follow  it  as  a  clue. 

Outcome. — During  the  first  three  days  the  diagnosis  was  not  made; 
and  later  it  was  discovered  that  he  has  for  three  years  used  drinking- 
water  coming  through  30  feet  of  lead  pipe.  His  blood-pressure  was  found 
to  be  185  mm. 

On  December  17th  his  attacks  of  colic  were  less  marked,  but  sudden 
muscular  weakness  in  both  arms  appeared  for  the  first  time.  On  Decem- 
ber 24th  he  was  free  from  colic  and  the  urine  had  cleared  up,  but  the  arms 


EPIGASTRIC   PAIN  17I 

and   back   showed   very   marked   muscular   weakness.     On   this   day 
(the  24th)  a  well-marked  lead  line  was  found  on  the  gums,  visible  only  on 
the  inner  side  of  the  teeth  of  tJie  lower  jaw. 
Diagnosis. — Plumbism. 

Case  77 

A  negro  of  sixty-four  entered  the  hospital  August  7,  1907.  He 
stated  that  his  mother  died  at  eighty-five  "of  worry."  His  family  his- 
tory is  otherwise  not  remarkable.  He  now  complains  of  se\-ere  epigastric 
pain  which  had  been  present  for  three  months.  During  the  Civil  War 
he  drank  a  quart  of  whisky  daily.  Fifteen  years  ago  he  had  a  venereal 
sore  which  was  treated  at  the  Boston  Dispensary  with  calomel  locally 
and  iodid  of  potassium  internally.  He  was  treated  for  six  months  and 
noticed  no  secondary  symptoms.  He  says  it  was  his  habit  to  take  three  or 
four  glasses  of  whisky  a  day  and  three  or  four  beers,  but  for  the  past 
four  months  he  has  abstained.  He  smokes  and  chews  five  cents'  worth 
of  tobacco  a  day. 

At  the  onset  of  the  pain,  three  months  before,  he  fell  in  the  street, 
although  he  was  not  unconscious.  Since  that  time  the  pain  is  apt  to 
radiate  from  the  epigastrium  across  his  chest  or  up  his  left  side  and 
through  his  back.  Occasionally  it  shoots  from  the  lower  part  of  his  back 
up  to  his  left  shoulder,  or  from  his  right  hip  down  his  leg,  but  it  is  worst  in 
the  epigastrium. 

Four  weeks  ago  he  was  examined  at  the  Boston  Dispensary  and 
thinks  that  he  was  ruptured  at  that  time.  He  has  had  no  vomiting,  head- 
ache, or  palpitation.  In  January,  1907,  he  weighed  180  pounds;  in  June, 
145  pounds;  now,  140.     His  digestion  is  good. 

Physical  examination  shows  a  pallor  of  the  mucous  membranes.  The 
heart  is  negative  except  for  accentuation  of  the  aortic  second  sound. 
The  carotid  arteries  are  i)rominent  and  easily  palpable.  The  blood- 
pressure  is  130  mm.  of  mercury.  The  right  lung  shows  a  consider- 
able number  of  coarse  rales  below  the  sca|)ula,  with  modera  e  dulness 
extending  to  the  base  of  the  lung.  One  and  a  half  inches  below  the  right 
costal  margin  is  a  rounded  nodule  an  inch  and  a  half  in  diameter,  con- 
siderably elevated,  apparently  not  connected  with  the  skin.  It  is  some- 
what movable,  not  tender,  and  does  not  descend  with  respiration.  There 
is  dulness  in  l)oth  flanks,  shifting  with  change  of  position.  The  ].eiiis  is 
six  inches  in  circumference,  markedly  edematous,  as  is  tlie  pcriiuiim. 
The  motions  of  the  back  are  limited  and  ]Kunful.  A  rectal  oxaniinatiiMi 
shows  that  the  prostate  is  the  size  of  a  small  grape-fruit,  wry  P.rm,  im- 


172  DIFFERENTIAL  DIAGNOSIS 

movable  in  the  pelvis,  and  encroaching  markedly  upon  the  rectum. 
The  right  testis  is  enlarged  and  tender. 

Red  cells,  2,696,000;  differential  count  normal;  white  cells,  14,200; 
hemoglobin,  45  per  cent. 

Discussion. — Abdominal  aneurysm  must  certainly  be  considered  as 
a  cause  of  pain  like  that  described  in  this  case,  especially  when  there 
is  so  well  authenticated  a  history  of  syphilitic  infection.  The  enlarged 
testicle  would  then  naturally  be  explained  as  syphilitic  orchitis.  The 
sudden  onset  of  the  pain  and  its  prostrating  effects  might  be  accounted 
for  by  a  partial  rupture  of  the  aneurysmal  sac. 

Against  this  diagnosis,  howe\'er,  is  the  evidence  furnished  by  rectal 
examination.  I  know  of  no  syphilitic  lesion  which  will  produce  such 
changes  in  the  prostate.  Another  fact  of  importance,  which  came  to 
light  later,  was  the  inefHiciency  of  a  prolonged  course  of  antisyphilitic 
treatment  which  he  had  recently  undergone.  Malignant  disease  is 
certainly  the  commonest  cause  for  an  extensive,  hard,  immovable  tumor 
connected  with  the  prostate  gland.  This  would  easily  account  for  the 
anemia  and  for  the  nodule  in  the  abdominal  wall,  though  both  of  these 
might  possibly  be  accounted  for  also  by  syphilis. 

If  malignant  disease  is  the  correct  diagnosis,  why  was  the  patient  so 
suddenly  stricken  that  he  fell  in  the  street  three  months  before?  I  can 
give  no  confident  answer  to  this  question.  Possibly  his  habits  have  some- 
thing to  do  with  explaining  it. 

Outcome. — The  patient  died  on  the  tenth  of  August.  Autopsy  showed 
sarcoma  of  the  right  testis,  with  metastasis  in  the  prostate,  adrenal  glands, 
small  intestine,  bronchial  lymphatic  glands,  pleura,  pericardium,  and 
abdominal  wall. 

Diagnosis. — Sarcoma  testis  with  metastases. 

Case  78 

A  colored  woman  of  twenty-four  entered  the  hospital  August  r,  igoy. 
Seven  months  ago  she  began  to  complain  of  a  severe  steady  pain  about 
the  center  of  the  abdomen,  a  little  more  on  the  left  than  on  the  right. 
At  this  time  a  large,  hard  tumor  was  discovered  near  the  navel.  For 
three  months  following  this  she  had  many  attacks  of  pain  in  the  same 
region,  and  her  temperature  ranged  from  100°  to  105°  F.  The  lump  in 
the  mean  time  decreased  in  size.  For  the  last  four  months  slie  has  had 
occasional  spells  of  pain  lasting  two  or  three  days.  She  docs  not  feel 
feverish.  For  the  past  four  months  she  has  had  severe  epigastric  ]:>ains, 
coming  on  every  fifteen  minutes,  lasting  two  or  three  minutes,  and  often 
leading  to  vomiting,  but  for  the  ])ast  twenty-four  hours  she  has  been  free 


EPIGASTRIC    PAIN 


173 


from  pain.  She  has  lost  twelve  pounds  in  the  past  seven  months,  but 
until  the  last  four  days  has  not  felt  very  much  weakness.  Nose-bleed 
has  been  frequent  all  her  life,  and  has  been  more  apt  to  come  at  the 
menstrual  period.  Her  bowels  have  been  constipated  for  years,  but  with 
medicine  have  usually  moved  once  a  day.  Temperature,  never  above 
99°  F.     Hemoglobin,  80  per  cent.;  leukocytes,  8800;  urine,  normal. 

Physical  examination  shows  nothing  abnormal  in  the  chest.  The 
abdomen  is  held  very  stiffly,  especially  in  the  lower  portion,  where  there 
is  slight  dulness.  Much  tenderness  is  complained  of  throughout.  Noth- 
ing else  could  be  made  out  on  account  of  this  tenderness.  By  vagina  a 
band  could  be  felt  to  the  right  of  the  uterus,  but  the  fundus  could  not  be 
palpated  on  account  of  abdominal  spasm.  Immersion  in  a  warm  bath 
failed  to  relax  the  abdominal  muscles,  and  even  under  ether  the  spasm  did 
not  entirely  relax. 

Discussion. — Chnical  experience  teaches  that  whenever  a  negress  is 
sick  and  the  symptoms  are  below  the  waist,  fibroid  tumor  of  the  uterus 
usually  turns  out  to  be  the  diagnosis.  The  abdominal  examination  was 
so  unsatisfactory  in  this  case  that  nothing  definite  could  be  said  regard- 
ing the  uterus.  The  lump  which  was  so  readily  felt  some  months 
before  would  play  in  very  well  with  the  idea  of  a  fibroid  tumor,  but  its 
apparent  decrease  in  size,  the  prolonged  fe^'er  (three  months'  duration) , 
and  the  generalized  abdominal  si)asm  do  not  fit  well  with  this  diagnosis. 

Pelvic  peritonitis  originating  in  a  pus-tube  would  explain  the  band 
felt  by  the  vagina  and  the  tenderness  of  the  lower  abdomen,  but  would 
not  account  for  the  long  fever,  the  wide  extent  of  the  abdominal  spasm, 
and  the  tumor  near  the  uml^ilicus.  Tuberculous  peritonitis,  however, 
will  explain  all  these  facts,  and  is,  moreover,  exceedingly  common  in 
young  colored  folks. 

Outcome. — On  August  7th  the  abdomen  was  0T'»cned  and  showed 
tuberculous  peritonitis,  the  viscera  irregularly  matted  together;  no  fiuid. 

Diagnosis. — Tuberculous  peritonitis. 

Case  79 

A  married  woman  of  thirty-eight,  a  French  Canadian,  entered  tb.e 
hospital  December  10,  IQ07,  for  chronic  abdominal  ])ain  \\luch  has  lasted 
for  sex'cral  weeks  and  apparently  lias  inca|)acitatc(i  licr  for  any  work. 
This  ])ain  has  troubled  her  on  and  off  for  three  }ears  and  a  halt. 
At  times  it  is  \'er}'  sewrc  and  interferes  much  with  lier  slii-p.  Now 
it  is  ])resent  every  day;  fornierl}-  she  wcnild  lia\e  resjiile  from  il  for 
many  weeks  at  a  time.  It  is  not  affected  1)V  eating  nor  hy  t!ie  time  (»f 
day.     Her  appetite   is   fair,  and   she  has   ne\'er   been   jaiiiKheed.      She 


174  DIFFERENTIAL   DIAGNOSIS 

vomits  occasionally,  the  vomitus  not  being  in  any  way  characteristic. 
Her  bowels  move  about  once  in  three  days.  She  has  no  cough  and  no 
headache,  but  thinks  she  has  lost  20  pounds  in  the  past  eight  months, 
and  has  been  unable  to  work  during  that  time  on  account  of  pain. 

Physical  examination  showed  considerable  loss  of  weight  and  pallor 
of  the  mucous  membranes.  Temperature,  pulse,  and  respiration  normal. 
The  chest  was  normal,  the  abdomen  somewhat  retracted,  rigid,  tym- 
panitic throughout,  and  tender  in  the  epigastrium;  no  masses  felt.  The 
blood  and  urine  showed  nothing  abnormal. 

Discussion. — The  symptoms  are  strikingly  like  those  of  the  last  case 
(tuberculous  peritonitis),  but  in  the  present  case  there  are  weeks  of 
freedom  from  SAinptoms  and  no  fever  has  been  recorded.  All  the  ordi- 
nary clues  suggested  by  the  cases  last  studied  were  followed  up  quite 
fruitlessly.  We  could  obtain  no  positive  evidence  of  an  intestinal  stric- 
ture, of  lead-poisoning,  of  peptic  ulcer,  cholelithiasis,  or  of  any  form  of 
peritonitis.  There  seemed  no  reason  to  suspect  the  kidney  or  any  part 
of  the  urinary  tract. 

Under  these  conditions  it  is  proper  to  ask  ourselves  whether  the 
symptoms  may  not  be  due  to  pure  constipation?  It  seems  extraordinary 
that  a  loss  of  20  pounds  in  weight  should  be  brought  about  by  this  cause. 
Only  the  therapeutic  test,  however,  can  decide  the  question.  If  the 
symptoms  all  disappear  when  the  bowels  are  properly  regulated,  and  if  so 
long  as  they  continue  regular  there  is  no  recurrence  of  pain,  the  diag- 
nosis will  be  justified. 

Outcome. — Under  careful  diet,  with  sodium  bicarbonate  h  dram 
after  meals  and  mild  laxatives,  the  patient  ceased  to  have  pain  and  left 
the  hospital  in  six  days.  Her  subsequent  history  has  been  uneventful 
(1910). 

Diagnosis. — Constipation. 

Case  80 

A  Russian  Jew  of  thirty-two  entered  the  hospital  February  11,  1908. 
He  has  complained  for  five  months  of  epigastric  cramps  beginning  about 
4  P.  M.,  lasting  all  night  and  until  noon  the  next  day.  In  previous 
years  he  has  had  similar  attacks  occasionally.  The  pain  has  no  relation 
to  eating,  but  on  the  days  in  which  his  stomach  has  been  washed  out  in 
the  out-patient  department  he  has  l)cen  relieved.  He  has  a  good  ap- 
petite and  eats  well,  but  vomits  daily,  sometimes  spontaneously,  some- 
times purposely  for  relief  of  distress.  The  amount  of  vomitus  is  large — 
often  as  much  or  more  than  he  has  eaten  since  he  last  vomited.  His 
bowels  often  go  five  and  six  days  without  moving.     About  a  week  ago 


EPIGASTRIC   PAIN 


175 


he  woke  at  2  o'clock  in  the  morning  feeling  very  faint.  He  soon  began 
to  be  ''choked  up,"  and  for  twenty-four  hours  had  great  difficulty  in 
breathing.  About  a  year  ago  he  weighed  145  pounds.  His  present 
weight  is  1 14  pounds.  He  was  formerly  a  painter,  but  has  had  nothing 
to  do  with  lead  for  thirteen  years. 

Physical  examination  is  negative,  except  that  there  are  tenderness 
and  some  spasm  under  the  right  costal  border.  The  blood  and  urine 
are  normal.  His  stomach  holds  108  ounces  of  fluid.  The  contents,  ob- 
tained by  washing,  smell  strongly  of  organic  acids,  and  it  is  difficult  to  get 
the  wash-water  clear.  On  inflation,  the  lower  border  of  the  stomach 
reaches  to  a  point  midway  between  the  navel  and  the  pubic  bone. 
Sahli's  test  was  administered,  with  the  following  result:  300  c.c.  of  the  test 
fluid  were  given.  After  one  hour  the  total  residue  was  315  c.c,  of  which 
109  c.c.  are  test  fluid  and  206  c.c.  secretion;  therefore  the  percentage  of 
test  fluid  passed  from  the  intestine  in  one  hour  is  63  per  cent,  as  compared 
with  the  normal  of  75  to  90  per  cent.;  the  hydrochloric  acid  of  the  pure 
gastric  juice,  3.4  per  cent.;  average  normal,  3.5  per  cent.  Diagnosis: 
deficient  motility  with  hypersecretion.  His  chief  complaints  during  his 
stay  in  the  hospital  were  a  burning  epigastric  pain,  flatulence,  and  con- 
stij)ation.     He  received  no  relief  from  diet,  medication,  or  gastric  lavage. 

Discussion. — We  repeated  in  this  case  the  therapeutic  test  used  so 
successfully  in  the  last,  but  even  when  the  bowels  were  in  a  perfectly 
satisfactory  condition,  the  suffering  continued  without  respite.  Con- 
stipation, therefore,  was  not  the  trouble;  it  was  the  result,  not  the  cause. 

Lead-poisoning  was  excluded  by  the  study  of  the  blood  and  the 
gums. 

Tenderness  and  s[)asm  under  the  right  costal  border  occurring  in  a 
patient  who  suffers  from  paroxysmal  epigastric  pain  compel  us  to  con- 
sider gall-stones.  This  possibility  cannot  be  ruled  out,  and  was  one  of  the 
alternatives  in  the  mind  of  the  surgeon  who  later  opened  the  al^domcn. 

Obviously,  however,  there  must  be  something  wrong  outside  the 
gall-ljladder,  for  the  patient's  stomach  is  markedly  dilated  and  does  not 
em])ty  itself  properly.  Gastric  stasis,  however,  may  be  one  of  the  disas- 
ters following  in  the  train  of  re})eated  gall-stone  attack  and  as  a  resu.lt  oi 
the  adhesions  thus  ])roduced. 

For  gastric  cancer — that  commonest  of  all  causes  of  ])yIoric  stenosis-- 
the  history  seems  to  be  too  long  in  this  case.  Yet  can  we  explain  the 
loss  of  weight  on  any  other  hypothesis?  In  answering  this  last  (|uesti()n 
it  is  worth  while  to  state  emphatically  that  ])atients  ma}'  lose  a  tilth  or 
a  (juarter  of  their  weight  within  a  few  months  as  a  result  either  of  gall- 
stones or  of  i)ei)tic  ulcer. 


176  DIFFERENTIAL   DIAGNOSIS 

In  the  present  case  all  that  was  certain  before  operation  was  the 
existence  of  an  obstruction  to  the  outflow  of  gastric  contents.  As  a 
cause  for  this,  the  scar  of  a  duodenal  ulcer  and  the  adhesions  resulting 
from  repeated  gall-stone  attacks  were  the  alternatives  most  seriously  con- 
sidered. 

Outcome. — Accordingly,  on  February  19th  the  abdomen  was  opened. 
No  disease  was  found  in  the  stomach,  duodenum,  or  gall-bladder,  but 
the  pylorus  was  considerably  obstructed  by  adhesions.  Gastro-enter- 
otomy  was  done.  After  the  operation  the  patient  improved,  and  by 
March  13th  seemed  to  be  in  excellent  condition  except  for  weakness.  On 
May  20th  he  was  discharged,  wholly  free  from  gastric  symptoms. 

Diagnosis. — Pyloric  adhesions. 

Case  81 

A  married  woman  of  thirty-two  has  been  complaining  for  some 
months  of  acute  epigastric  pain  coming  immediately  after  meals,  lasting 
about  fifteen  minutes,  and  relieved  by  the  belching  of  gas.  She  entered 
the  hospital  on  July  29,  1907.  She  had  sufi"ered  from  typhoid  fever 
at  the  age  of  fifteen,  from  diphtheria  at  twenty,  scarlet  fever  at  twenty- 
two,  "peritonitis"  five  years  ago.  She  has  been  married  fifteen  years, 
but  has  had  no  children  and  no  miscarriages.  Five  years  ago  she  weighed 
250  pounds,  and  she  thinks  she  has  gained  in  weight  lately.  She  is  in 
the  habit  of  taking  two  or  three  drinks  of  whisky  a  week  for  the  "  blues." 
Four  days  ago  she  ate  very  heartily  at  supper-time.  At  i  o'clock 
the  following  morning  she  was  taken  with  severe  epigastric  pain,  which 
has  persisted  ever  since. 

After  palpation  of  the  epigastrium  the  pain  becomes  spasmodic 
and  seems  to  go  straight  through  to  the  back.  It  is  worse  with  every 
deep  breath,  and  is  increased  by  emotion. 

The  bowels  were  moved  last  night  for  the  first  time  during  this 
illness,  as  a  result  of  laxati\'e  pills.  The  pain  has  pre^■ented  sleep,  and 
last  night  she  thinks  she  was  delirious.  The  patient's  temperature  is 
102°  F.;  |)ulsc,  100;  respiration,  30.  There  is  tenderness  on  percussion 
over  the  lower  part  of  both  lungs  l^ehind,  but  nothing  else  abnormal  is 
made  out.  The  abdomen  is  somewhat  hollow  a])o\'e  the  umbilicus, 
rather  full  below;  the  abdominal  wall  very  thick  and  flaljliy.  There  is 
slight  rigidity  in  the  lower  part,  less  in  the  epigastrium,  \vlicre  the  pain 
is  worst.  Dee])  ])ressurc  elicits  expressions  of  i)ain  in  ])()tli  the  lower 
quadrants  and  in  tlie  right  hypochondrium.  The  edge  of  the  li\er 
cannot  l^e  made  out. 


EPIGASTRIC    PAIN 


177 


Next  morning  the  pain  was  more  definitely  localized  in  the  epi- 
gastrium, and  the  temperature  and  pulse  remained  elevated,  while  the 
white  corpuscles  had  risen  from  13,400  to  17,000. 

Discussion. — Out  of  this  very  checkered  past  history,  with  its 
suggestions  of  dyspepsia,  peritonitis,  and  alcoholism,  no  clear  indica- 
tions for  diagnosis  emerge.  The  constipation  and  the  very  wide-spread 
character  of  the  pains,  both  in  the  back  and  the  front  of  the  body, 
are  common  features  of  some  types  of  neurosis,  but  the  presence  of 
fever  and  leukocytosis  make  neurosis  very  unlikely.  In  the  foreground 
of  the  clinical  picture  are  the  epigastric  pain  and  tenderness  of  acute 
onset.  Many  possibilities  may  emerge,  but  at  present  no  clear  diagnosis 
is  possible. 

The  problem  here  presented  is  a  very  familiar  one.  We  have 
good  reason  to  believe  that  in  the  course  of  twenty-four  or  forty-eight 
hours  the  diagnosis  will  be  much  clearer,  but  is  it  not  dangerous  to 
wait  so  long?  Should  not  an  operation  be  done  at  once  before  more 
dangerous  symptoms  appear?  No  definite  rules  can  be  given  by 
following  which  we  can  soh-e  this  difllicully  in  e\'ery  case.  The  decision 
rests  mainly  upon  two  points  of  observation: 

1.  How  sick  is  the  patient? 

2.  Is  she  getting  worse  from  hour  to  hour? 

An  answer  to  the  first  question  depends  on  long  and  mature  clinical 
experience.  A  general  impression  is  gained,  of  which  no  very  clear 
account  can  be  given.  The  look  of  the  patient's  face  and  the  quality 
of  the  pulse  are  perhaps  the  most  important  items  in  the  judgment. 

More  important  is  the  demonstrable  change  under  ol^servation  of 
some  of  the  measurable  data,  such  as  temperature,  pulse,  res])iration, 
leukocytosis,  the  degree  and  area  of  spasm,  tenderness,  and  pain. 
\\'hile  we  are  watching  the  course  of  these  varial^Ies.  it  is  quite  likely 
that  the  ])ain  and  tenderness  will  ha\e  time  to  "settle."  Careful 
observation  of  most  cases  of  this  kind  brings  out  three  stages: 

1.  Tlie  initial  pain,  its  location  being  of  great  diagnostic  ^■alue  if 
the  history  is  clear  and  definite. 

2.  The  subsecjuent  radiations  of  this  ])ain,  often  most  confusing. 

3.  Its  final  "settling"  in  a  single  spot,  most  important  in  diagnosis. 
but  often  dangerous  to  wait  for. 

Tlie  symptoms  do  not  seem  to  l)e  \'iolent  enougli  for  pcrforati'd 
])e])tic  ulcer  or  for  acute  ]>ancreatitis,  tliough  neitiu^r  of  thtsc  caii  be 
ruled  out.  Gall-stones  is  the  next  most  fre(]uent  cause  for  i>ain  of 
this  type,  ])ro\'ided  lead,  tabes,  constipation,  ])i'ricarditis,  and  ani:ina 
pectoris  are  excluded,  as  is  easily  j)ossil)le  in  the  ])resenl  case.      Since 


1,' 


178  DIFFERENTIAL   DIAGNOSIS 

there  are  fever  and  leukocytosis,  it  is  reasonable  to  believe  that  some 
cholecystitis  has  also  occurred  here. 

Outcome. — On  the  afternoon  of  the  thirtieth  of  July  operation 
showed  an  enlarged,  edematous,  partially  gangrenous  gall-bladder, 
with  one  faceted  stone  within. 

The  yjatient  made  a  good  recovery. 

Diagnosis. — Cholehthiasis  and  gangrenous  gall-bladder. 

Case  82 

A  woman  of  forty-eight  entered  the  hospital  February  14.,  1908. 
She  has  had  four  children,  all  of  whom  are  now  dead.  The  first  was  a 
congenital  idiot;  the  second  had  water  on  the  brain;  the  third  was 
still-born,  and  the  fourth  died  at  three  years  of  pneumonia.  She  had 
repeated  convulsions  during  the  latter  months  of  her  third  pregnancy. 
During  the  others  she  had  no  such  trouble.  She  has  had  no  miscarriage. 
Her  habits  are  good,  but  she  has  usually  passed  her  water  eight  or  ten 
times  each  night  during  the  past  ten  years. 

For  the  past  seventeen  years  she  has  had  many  attacks  of  epigastric 
pain,  with  distention  and  belching.  The  pain  has  never  been  colicky 
or  accompanied  by  jaundice,  but  has  radiated  to  the  back,  and  has 
sometimes  been  severe  enough  to  require  morphin.  The  attacks  of 
pain  have  no  relation  to  mental  conditions  nor  to  the  character  or  time 
of  meals.     Her  weight  is  unchanged. 

Two  and  a  half  weeks  ago  she  had  a  sudden  attack  of  pain,  worse 
than  at  any  previous  time,  and  vomited  several  times  in  the  first  twenty- 
four  hours.  She  had  fever  for  five  days,  and  has  been  in  bed  ever 
since.  She  has  had  daily  chills,  lasting  from  fifteen  to  twenty  minutes 
each,  and  recurring  about  the  same  hour.  Her  bowels  have  been  con- 
stipated, and  she  has  taken  only  liquid  food  for  two  weeks. 

Temperature,  pulse,  and  respiration  are  normal.  The  patient  is 
very  obese.  The  sclera  shows  a  very  slight  yellowish  tinge.  Tlie  chest 
is  negative,  and  the  abdomen  shows  nothing  but  general  tenderness. 
At  a  point  2}  inches  below  the  costal  margin  a  rounded  edge  ('])resum- 
ably  the  liver)  is  felt  to  descend  on  inspiration,  and  there  is  considera- 
ble tenderness  at  this  point  and  just  abo^•e  it.  The  surface  of  the  liver 
seems  irregular.  The  right  sacro-iliac  joint  is  tender  to  pressure,  and 
she  feels  better  with  a  pillow  under  the  ]nml)ar  sninc.  Her  pain  and 
vomitmg  continued  after  the  patient  entered  the  hosy)ital.  and  des])ite 
laxatives,  counterirritants,  and  starvation.  The  leukocyte  count  at 
entrance  was  8000,  but  rose  on  the  tliird  day  to  17,000,  with  90  per 


EPIGASTRIC    PAIN 


179 


cent,  of  polynuclear  cells.  The  temperature  at  the  same  time  rose  to 
102°  F. 

Discussion. — When  a  woman's  pregnancies  have  resulted  as  in 
this  case,  syphilis  must  always  be  thought  of  as  a  possible  cause  for  any 
subsequent  symptoms.  The  presence  of  chills  and  the  suggestion  of  an 
irregular  liver  point  toward  that  organ  as  possibly  the  seat  of  a  syphilitic 
process.  On  account  of  such  chills  I  have  twice  known  patients  to  be 
drenched  with  quinin  for  weeks  at  a  time,  when  syphilis  of  the  liver  was 
the  true  diagnosis. 

In  this  case,  however,  the  normal  temperature  makes  us  wonder 
whether  the  chills  may  not  be  of  nervous  origin.  Trembling  and 
shivering  are  very  common  nervous  symptoms,  with  or  without  the  sen- 
sation of  cold,  and  under  these  conditions  often  get  mistaken  for  a  chill, 
which  usually  carries  with  it  the  presence  of  fever.  We  are  by  no  means 
certain,  however,  that  the  temperature  has  always  been  normal  previous 
to  February  14th;  indeed,  the  patient's  statement  directly  contradicts 
such  an  idea.  At  any  rate,  we  cannot  be  content  with  the  diagnosis  of 
psychoneurosis  in  view  of  the  quite  definite  physical  signs  described  above. 

Can  her  troubles  all  be  due  to  sacro-iliac  arthritis?  Attention  is 
drawn  to  this  point  by  the  tenderness  over  the  sacro-iliac  joint  and  the 
relief  following  support  of  the  lumbar  s])inc,  but  the  jaundice,  enlarged 
liver,  and  the  persistent  vomiting  cannot  be  thus  exy)laincd.  Pain  and 
tenderness  in  various  parts  of  the  abdomen  may  be  produced  through  the 
nerve  radiations  originating  in  sacro-iliac  disease.  Both  gall-stones  and 
appendicitis  may  thus  be  simulated.  But  in  this  case  we  have  other 
objective  signs. 

By  far  the  commonest  lesion  associated  with  a  picture  like  that  here 
gi\en  is  cholelithiasis,  and  although  the  case  is  atypical  in  various  respects, 
this  seems  to  l)e  the  most  reasonal^lc  diagnosis. 

Outcome. — 0])eration  showed  an  enlarged,  thickened,  and  perfor- 
ated gall-bladder,  surrounded  l)y  a  considerable  amount  of  pus,  and  con- 
taining numerous  gall-stones. 

Diagnosis. — Cholelithiasis  willi  perforations. 

Case  83 

A  school  l)oy  of  thirteen  entered  the  hos|)ital  February  14.  tqoS. 
Tn  November  and  D(Teml)er,  U)o6.  hv  had  an  acute  urethritis,  and 
gfmorocci  were  demonstrated  in  tlie  disrharge.  He  has  had  "rheu- 
matism" for  about  oni'  vear  in  tlie  jiast  three  vears.  in  jjenods  lasnng 
from  six  w(>eks  to  three  months.  His  familv  history  is  not  remarkal)le, 
and  he  has  been  well  for  the  i)ast  two  ^•ears. 


l8o  DIFFERENTIAL   DIAGNOSIS 

Seven  days  ago  he  began  to  have  epigastric  pain.  Five  days  ago  his 
knees  became  swollen  and  painful  on  motion,  and  he  took  to  his  bed, 
where  he  has  since  remained.  In  the  past  two  days  his  knees  have  im- 
proved and  no  other  joints  have  been  involved.  Yesterday  morning  he 
began  to  breathe  very  rapidly,  but  has  had  no  cough  and  no  vomiting. 

Physical  examination  shows  slightly  labored  breathing,  with  pallor 
of  the  mucous  membranes.  Temperature,  100.2°  F.;  pulse,  112;  res- 
piration, 28.  The  heart's  dulness  extends  into  the  sixth  interspace, 
two  inches  to  the  left  of  the  nipple-line.  The  right  border  extends  if 
inches  to  the  right  of  midsternum.  The  cardiohepatic  angle  is  ob- 
tuse. All  over  the  precordia,  but  loudest  at  the  apex,  a  systolic  mur- 
mur and  a  rough  diastolic  murmur  are  heard.  The  latter  is  also  heard 
over  the  lower  end  of  the  sternum.  In  the  left  back  there  is  dulness  ex- 
tending up  to  a  point  one  inch  above  the  lower  angle  of  the  scapula, 
thence  sloping  down  through  the  axilla  to  meet  the  cardiac  dulness. 
Over  most  of  the  dull  area  bronchial  breathing,  increased  voice-sounds, 
with  increased  tactile  fremitus,  and  fme  moist  rales,  are  heard.  At  the 
extreme  base,  where  dulness  is  most  marked,  the  intensity  of  voice- 
sounds  and  breath-sounds  is  very  slight.  Later  a  capillary  pulse  was 
demonstrated,  and  the  diastolic  murmur  was  shown  to  be  loudest  along 
the  left  edge  of  the  sternum,  but  also  fairly  loud  in  the  second  right 
interspace. 

At  no  time  was  there  any  cough.  The  leukocytes  ranged  between 
12,000  and  13,000;  the  urine  was  between  30  and  40  ounces  in  twenty- 
four  hours,  and  free  from  albumin. 

Discussion. — Ob\'iously,  this  boy  has  an  arthritis,  and  gonorrhea 
is  its  probable  cause.  The  problem  of  present  importance  is  to  deter- 
mine what  complications  have  occurred.  Evidently  some  infectious 
disease  is  still  going  on,  and  the  physical  signs  call  our  attention  especi- 
ally to  the  heart  and  the  lungs. 

Pneumonia,  with  or  without  empyema,  would  explain  the  signs  in  the 
right  Ijack,  and  it  is  a  very  familiar  fact  that  pneumonia  and  pleurisy  often 
begin  in  children  with  abdominal  pain.  The  absence  of  cough  l3y  no 
means  excludes  pneumonia. 

But  the  cardiac  signs  have  also  to  be  explained.  The  increased  area 
of  dulness  and  the  double  apical  murmur  are  the  ordinary  evidences  of 
endocarditis  with  disease  of  the  aortic  and  mitral  valve.  But  the  per- 
cussion lines  on  the  right  side  of  the  heart  (see  diagram)  are  more 
indicati\'e  of  pericarditis,  though  no  ty]:)ical  friction  is  described.  If 
a  pericardial  effusion  were  present,  it  might  account  not  only  for  the  per- 
cussion outlines  and  the  auscultatorv  abnormalities,  Ijut  also  for  the 


Fig.  29. — l'erci.issi()n  outlines  in  a  patient  com])laining  chicny  of  ci)igastric  i)ain.     (See 

also  I'ig.   30.) 


Fig.  30. — Signs  (U'liionstralilc  in  a  casr  of  iMidoiicritardiiis.      (Sec  also  I'ig.  29.,: 


EPIGASTRIC    PAIN 


I8l 


signs  in  the  back  of  the  left  lung,  since  this  is  just  the  area  of  lung  on 
which  a  pericardial  effusion  exerts  pressure  in  bed-ridden  patients. 
By  such  pressure  sufficient  condensation  of  the  lung  is  produced  to  sim- 
ulate the  signs  of  pneumonia.  It  is  impossible  to  exclude  a  patch  of 
pneumonia  complicating  the  other  troubles  present,  but  experience  shows 
that  we  are  more  apt  to  be  right  when  we  explain  a  clinical  picture  by 
one  diagnosis  rather  than  by  two.  Pericarditis,  therefore,  seems  the 
most  reasonable  working  hypothesis. 

Outcome. — The  temperature  gradually  subsided  in  ten  days.  The 
murmurs  disappeared,  and  the  boy  seemed  entirely  well  by  February 
28th. 

Diagnosis. — Acute  pericarditis. 

Case  84 

A  sexton  of  sixty-five  was  first  seen  December  16,  1907,  complaining 
of  paroxysmal  abdominal  pain  relieved  only  by  morjjhin.  Aljout  three 
years  ago  he  began  to  suffer  from  dyspnea  and  swelling  of  the  legs. 
This  trouble  has  been  present,  off  and  on,  ever  since,  Ijut  he  notices  that 
it  is  better  if  he  is  working  hard  than  if  he  sits  around  the  house. 

In  July,  1907,  he  had  an  attack  of  sudden,  cramp-like  pain  in  the  upper 
abdomen,  accompanied  by  dyspnea  and  persistent  vomiting  of  foul 
green  ffuid.  After  twenty-four  hours  the  pain  was  relie\-ed  by  a  sub- 
cutaneous injection  of  morphin.  Since  that  time  he  has  had  similar 
attacks,  gradually  increasing  in  frequency  and  diminishing  in  severity. 
He  now  has  them  e\'ery  second  or  third  day,  but  docs  not  vomit  with 
them.  In  the  last  three  months  he  has  noted  that  during  the  day  and 
night  before  an  attack  he  passes  large  amounts  of  pale  urine,  and  on  the 
day  following  an  attack  small  amounts  of  dark  urine.  His  aljdomen  is 
often  bloated,  but  this  sul^sidcs  without  treatment. 

Physical  examination  shows  that  the  ])U])ils  are  equal  and  react  well. 
The  tongue  is  large  and  smooth,  especially  in  the  j)osterior  portion. 
The  apex  of  the  heart  extends  one  inch  outside  the  nij)])le-line  in  the 
fifth  space.  The  first  sound  at  the  apex  is  weak,  the  second  sound  e\ery- 
where  accentuated;  no  murmurs  are  heard.  Bk)()d-])ressin-e  ranges 
between  140  and  160  mm.  The  artery  walls  are  stiff'  and  tcjrtuous. 
The  alxlomen  shows  general  Noluntary  spasm,  and  the  edge  of  the  li\"er 
is  felt  one  inch  below  tlie  costal  margin.  The  knee-jerks  cannot  be  ob- 
tained even  on  rcenforcemcnt.  The  urine  awrages  a])out  40  ounces  in 
twenty-four  hours,  with  a  gravity  of  a])out  1020.  There  is  no  albumin, 
but  a  few  hyaline  granular  casts  are  seen  in  the  sediment.  The  while 
corpuscles  are  6100. 


1 82  DIFFERENTIAL   DIAGNOSIS 

During  his  month  in  the  hospital  the  patient  had  many  attacks  of 
abdominal  pain,  always  coming  on  at  night,  relieved  by  morphin  so 
completely  that  next  morning  he  felt  well  and  wanted  to  get  up.  Nitro- 
glycerin and  amyl  nitrite  were  repeatedly  tried  without  any  relief. 
Most  of  the  attacks  of  pain  -were  preceded  by  slight  shortness  of  breath. 
The  patient  sometimes  vomited  during  an  attack. 

Dr.  James  J.  Putnam  examined  the  patient  and  said  that  the  loss  of 
knee-jerk  might  be  due  either  to  spinal  arteriosclerosis  or,  more  prob- 
ably, to  the  diphtheria  of  his  youth. 

Discussion. — In  a  patient  who  has  no  knee-jerks  and  complains  of 
paroxysmal  abdominal  pain,  the  thought  of  tabes  should  automatically 
rise  in  our  minds.  In  this  case  tabes  must  remain  a  possibility  unex- 
cluded  to  the  last,  though  it  is  very  unusual  to  find  the  pupils  norm.al  and 
the  other  signs  of  tabes  (lightning  pains,  sphincteric  disturbances,  sen- 
sory abnormalities,  ataxia,  syphilitic  history)  all  absent. 

Angina  pectoris  (or  angina  abdominalis)  is  the  natural  inference 
when  we  come  to  take  account  of  the  evidences  of  failing  heart  power 
and  of  arterial  degeneration.  But  angina  is  almost  never  accompanied 
by  ^'omiting,  and  it  is  rare  to  find  a  case  absolutely  unrelieved  by  the 
nitrites. 

Though  the  pain  is  not  in  the  typical  place  and  has  not  the  typical 
radiations  of  cholelithiasis,  there  are  a  number  of  points  suggesting  that 
diagnosis.  It  would  1:>e  \ery  unusual,  however,  to  find  no  fe\'er  or  chill 
in  the  history  of  a  patient  who  has  had  gall-stone  pains  for  six  months. 
Further,  the  association  of  the  pain  with  dyspnea  and  with  changes  in 
the  amount  of  urine  would  be  \'ery  unexpected  in  cholelithiasis. 

Peptic  ulcer  might  produce  such  a  pain,  but  the  brief  paroxysms 
completely  relieved  by  morphin  are  not  at  all  characteristic  of  that 
disease.  Further,  it  is  very  rare  to  find  an  active  peptic  ulcer  coincident 
with  evidences  of  failing  heart. 

Plumbism,  simple  constipation,  and  intestinal  obstruction  by  cancer 
can  easily  be  ruled  out. 

It  seems  to  me  of  importance  to  notice  the  background  of  this  case. 
For  nearly  three  years  pre\"ious  to  the  onset  of  the  sym])toms  now 
com])lained  of  the  patient  had  suffered  from  dyspnea  and  edema  of  the 
legs.  Physical  examination  at  the  ])resent  time  seems  to  indicate  that 
this  is  not  due  to  primary  valvular  trouble,  but  rather  to  vascular  degener- 
ation. It  is  j)0ssil)le  that  all  the  symptoms  may  l)e  due  to  this  same  cause 
acting  upon  different  organs. 

It  is  a  welkknown  fact  that  in  arteriosclerotic  subjects  there  apj)ear 
from  time  to  time  a  great  variety  of  paroxysmal  attacks  whicli  in  former 


EPIGASTRIC    PAIN 


183 


years  were  attributed  solely  to  the  obliteration,  embolic  closure,  or  rup- 
ture of  one  or  another  blood-vessel.  In  the  light  of  more  careful  post- 
mortem study  we  have  come  to  speak  of  these  paroxysmal  attacks  as 
vascular  crises}  The  idea  of  vascular  spasm  takes  the  place  of  the  older 
idea  of  gross  vascular  lesion,  in  view  of  the  fact  that  postmortem  there 
is  often  no  gross  vascular  lesion  to  be  found.  Under  this  general  head- 
ing of  vascular  crises  belong  in  all  probability  many  of  the  transient  hemi- 
plegias, monoi)legias,  aphasias,  comas,  local  or  general  spasms  formerly 
explained  as  due  to  permanent  anatomic  lesions.  Cardiac  vascular  crises 
may  be  supposed  to  account  for  the  cases  of  fatal  angina  pectoris  without 
marked  narrowing  of  the  coronary  arteries.  The  gastric  and  other  crises 
occurring  in  tabes  are  very  possibly  to  be  accounted  for  in  the  same  way. 

In  the  present  case  there  are  three  sets  of  data  supporting  the  hypothe- 
sis of  vascular  crisis:  (a)  The  curious  urinary  changes  which  strongly 
suggest  the  "urina  spastica"  seen  in  vasomotor  affections  and  hysteric 
states;  {h)  the  swelling  of  the  abdomen  during  attacks;  and  (c)  the  associ- 
ation with  dyspnea. 

I  ha\e  already  stated  that  it  is  impossible  to  exclude  tabes  in  this 
case,  ^^'ere  that  the  correct  diagnosis,  tlie  mechanism  by  which  the 
attack  was  produced  would  be  the  same  as  under  the  hypothesis  of  vas- 
cular crisis  without  the  other  lesions  of  tabes. 

Outcome. — He  died  of  pneumonia  at  the  end  of  a  month;  the 
autopsy  showed  arteriosclerosis  with  hypcrtroj)hy  and  dilatation  of  the 
heart.  The  celiac  axis  and  the  coronary  arteries  were  only  slightly 
involved  in  the  arteriosclerotic  process.     No  tabes. 

Diagnosis. — Arteriosclerosis;  vascular  crises. 

Case  85 

A  school-boy  of  ten  entered  the  hospital  January  28,  1908,  on  ac- 
count of  e])igastric  i)ain  \vhich  came  on  niglit  before  last  after  a  supper 
of  pork  and  beans  with  cheese.  It  has  ])revented  him  from  sleeping 
since  then. 

lie  says  tliat  it  feels  as  if  some  one  had  ])unclH'(l  him  in  the  stomach. 
l)realhing  or  ga])ing  ga\e  paiii  at  this  point  and  in  tb.c  left  axilla.  He 
has  almost  constant  nausea,  and  has  been  fcwrish  since  yesterda}'  UK^rn- 
ing.  He  has  a  Itrother  who  has  been  treated  at  tiie  C'hildrenV  II()S])ital 
for  tuberculosis  of  the  knee. 

At  entrance  his  temperature  was  102.4°  F.;  i)ulse.  08:  rcspiia- 
tion,  30,  and  accompanied  by  a  grunt.  He  now  complains  of  oain 
both    in  the   e])igastrium   and  at   tlie   top    of    the    slernum.     The    ear- 

'  I'cir  I'al's  accdUiil  nf  thr^f  cri'^fs  see  p.  ;  i. 


1 84  DIFFERENTIAL  DIAGNOSIS 

diohepatic  angle  is  obtuse,  and  over  the  area  shown  in  the  diagram 
(Fig.  31)  there  is  a  to-and-fro  friction  sound,  loudest  in  the  second 
right  interspace.  Physical  examination  is  otherwise  normal.  The 
white  cells  number  9600;  the  urine  is  negative.  The  day  after  entry  the 
friction-rub  disappeared  and  the  temperature  fell  to  normal  on  the 
second  day.  On  February  5th  he  was  playing  about  the  ward,  and  a 
fairly  loud  systolic  murmur  was  heard  at  the  apex  and  in  the  axillas. 
The  cardiohepatic  angle  was  now  acute. 

Discussion. — Some  digestive  disturbance  is  naturally  the  first  ex- 
planation which  occurs  to  us,  since  the  symptoms  followed  so  imme- 
diately upon  the  taking  of  a  heavy  meal;  but  a  simple  digestive  upset  of 
this  kind  would  not  account  for  a  temperature  of  102.4°  F.  forty-eight 
hours  after.  In  all  probability  the  digestive  upset  was  a  result,  not  a 
cause,  of  the  present  trouble. 

Tuberculosis  of  the  spine  is  said  to  be  associated  with  epigastric 
pain,  such  as  is  here  present,  and  the  presence  of  tuberculosis  in  the 
patient's  brother  makes  it  proper  for  us  to  consider  this  disease  seriously. 
There  is  nothing,  however,  in  the  physical  exan)ination  to  support  any 
such  idea — no  spasm  of  the  erector  spinas  group  and  no  prominence  or 
tenderness  of  any  vertebra;  nor  are  there  any  indications  of  tuberculosis 
elsewhere. 

With  these  two  alternatives  excluded  and  with  due  regard  for  the  results 
of  the  physical  examination  the  only  reasonable  diagnosis  is  pericarditis. 
Indeed,  the  diagnosis  could  hardly  have  been  missed  except  by  reason  of 
the  all  too  common  error — ^the  failure  to  look  for  it. 

Outcome. — It  was  learned  subsequently  that  when  the  patient  was 
three  years  old  he  had  considerable  pain  and  weakness  in  his  legs,  ac- 
companied by  fever.     Recovery  was  uneventful. 

Diagnosis. — Pericarditis. 

Case  86 

A  brass-finisher  of  fifty-six  entered  the  hospital  on  January  30,  1908, 
with  a  negative  history  up  to  eight  weeks  ago,  although  he  had  been 
in  the  habit  of  taking  about  five  drinks  of  whisky  a  day  for  a  good 
many  years.  Eight  weeks  ago  he  began  to  have  abdominal  pain, 
worst  in  the  pit  of  the  stomach.  This  pain  is  sharp  and  piercing, 
almost  constant  of  late,  keeping  him  awake  at  night.  For  the  past 
week  or  two  it  has  run  up  under  the  left  costal  margin  at  times.  There 
have  been  no  vomiting  and  no  belching,  but  he  has  gradually  lost  his 
appetite  entirely.  Food  does  not  affect  the  pain  in  any  way.  His 
weight  lias  fallen  42  pounds  in  three  months.     His  bowels  are  regular. 


Fig.  31. — Fric-tiun-arca  and  i)(.'rcus>i()n  dUiliius  in  C'aie  iS5.     (  liit-f  coinplaiiU  is  epigastnc 

pain. 


EPIGASTRIC   PAIN 


185 


On  physical  examination  temperature,  pulse,  and  respiration  are 
normal,  likewise  the  lungs.  The  heart  shows  no  evidence  of  enlarge- 
ment, and  its  sounds  are  regular  and  of  good  quality.  At  the  apex 
there  is  a  faint  systolic  murmur  transmitted  to  the  axilla,  heard  also 
in  the  pulmonary  area  and  more  faintly  in  the  aortic  area.  All  over 
the  precordia  and  over  the  left  pectoral  is  heard,  during  inspiration 
alone,  a  faint,  grating,  systolic  sound,  loudest  in  the  third  space  and 
anterior  axillary  line.  In  the  fourth  space,  near  the  left  edge  of  the 
sternum,  is  heard  a  crackling  systolic  sound  not  affected  by  respiration. 
The  aortic  second  sound  is  considerably  accentuated;  the  artery  walls 
are  somewhat  thickened.  Examination  of  stools  shows  nothing  re- 
markable, the  guaiac  test  being  negative.  The  stomach  was  found  to 
hold  76  ounces  of  water.  The  lower  border  descended  if  inches  below 
the  na^^el.  After  a  test-meal  the  gastric  contents  showed  no  free  hydro- 
chloric acid  and  no  lactic  acid;   the  guaiac  test  was  negative. 

Discussion. — Whisky  is  so  old  a  friend  of  this  patient  that  it  is  not 
likely  to  begin  to  disagree  with  him  in  his  fifty-sixth  year.  Probably 
it  has  nothing  to  do  with  the  symptoms  in  this  case. 

Peptic  ulcer  might  produce  such  pain,  and  is  perfectly  consistent 
with  the  loss  of  42  pounds'  weight  in  two  months.  But  the  lack  of 
appetite,  the  entire  absence  of  vomiting  and  belching,  and  the  short 
duration  of  the  symptoms  make  this  unlikely. 

What  are  we  to  make  of  the  curious  signs  in  the  chest?  Have  they 
anything  to  do  with  the  symptoms  complained  of?  Inspiratory  systolic 
sounds,  absent  during  expiration,  and  best  heard  along  the  maro;ins 
of  cardiac  dulness,  constitute  the  commonest  type  of  so-called  cardio- 
respiratory murmur.  The  phenomenon  has  no  clinical  significance 
except  that  in  a  considerable  proportion  of  cases  it  is  found  to  be  asso- 
ciated with  pleural  or  pleuropericardial  adhesions,  v.hich  may  be  due 
to  tuberculosis.  The  same  may  be  said  of  systolic  crackling  sounds, 
which  occasionally  mystify  the  practitioner. 

It  is  well  to  make  it  a  rule  always  to  hunt  for  evidence  of  gastric 
cancer  when  a  patient  past  forty  comes  to  us  \\ilh  a  rccnii  and  unex- 
plained liislory  of  gastric  sym])toms,  mild  or  severe.  Errors  in  diet, 
worries,  and  such  causes  are  not  apt  to  take  effect  for  the  frst  time 
after  a  person  has  li\'ed  fifty-six  years.  If  gastric  s}'m])toms  arc  due 
to  any  cause  other  than  cancer,  careful  questioning  of  the  ])aLient  will 
usually  ])rove  that  they  ha\'e  existed  at  inter\"als  for  years.  In  the 
i)resent  case  tlie  e\'iclence  of  enlargement  of  the  stomach  and  the  abst-nce 
of  hydrochloric  acid  from  the  gastric  contents  are  chiell}'  of  conlirnia- 
tory  \-alue  as  ex'idence.  the  histor}"  being  tlie  inijiortant  thing. 


1 86  DIFFERENTIAL   DIAGNOSIS 

Very  characteristic  of  gastric  cancer  is  the  gradual  but  complete 
loss  of  appetite  in  this  case.  On  the  other  hand,  the  absence  of  vomit- 
ing and  of  any  relation  between  the  pain  and  the  taking  of  food  is  rather 
unusual. 

Outcome. — His  symptoms  were  somewhat  relieved  by  lo  grains 
of  orthoform,  given  four  times  a  day,  and  15  minims  of  dilute  hydro- 
chloric acid,  given  twenty  minutes  after  each  meal. 

The  patient  died  on  March  15th.  Autopsy  showed  cancer  of  the 
stomach. 

Diagnosis. — Gastric  cancer. 

Case  87 

A  bricklayer  of  fifty-two  entered  the  hospital  April  7,  1908,  with  a 
diagnosis  of  gall-stones.  His  family  history  and  past  history  were 
negative;  his  habits  good.  For  three  months  he  has  complained  of 
pain  in  the  epigastrium,  not  severe,  but  worse  after  eating,  and  usually 
radiating  to  the  right  back.  For  six  weeks  he  has  noticed  white  stools, 
dark  urine,  and  jaundice.  Throughout  this  time,  however,  his  appetite 
has  been  good,  and  he  has  had  no  vomiting. 

On  physical  examination  he  was  found  to  be  deeply  jaundiced, 
his  lungs  hyperresonant  in  front,  with  slightly  prolonged  expiration. 
Over  the  sacrum  was  a  soft,  flattened,  subcutaneous  prominence  the 
size  of  a  dollar.  Nothing  else  was  detected  on  physical  examination, 
abdominal  palpation  being  unsatisfactory,  owing  to  constant  rigidity. 
On  April  nth  the  abdomen  became  less  resistant,  and  an  indclinite 
mass  was  felt  in  the  region  of  the  gall-bladder.  A  stomach-tube  was 
passed,  and  the  capacity  of  the  organ  was  found  to  be  42  ounces  of 
water,  the  lower  border  extending  to  a  point  one  inch  below  the  na\'el. 
No  contents  were  found  in  the  fasting  stomach.  After  a  test-meal, 
however,  hydrochloric  acid  was  found  to  be  o.og.  Lactic  acid  test 
and  guaiac  test  were  negative. 

Discussion. — Excluding  congenital  cases,  an  afebrile,  persistent 
jaundice  usually  presents  to  us  the  problem  of  deciding  between  three 
causes : 

1.  Gall-stones  and  their  effects. 

2.  Cancer,  either  of  the  pancreas  or  bile-ducts,  occasionally  of  the 
liver  itself. 

3.  Cirrhosis. 

Hepatic  syphilis  is  considerably  less  frequent  as  the  cause  of  long- 
standing jaundice,  and  the  duration  is  here  assumed  to  be  sufficient 
to  exclude  the  acute  infectious  and  the  catarrhal  type  of  jaundice. 


EPIGASTRIC    PAIN 


187 


Against  gall-stones  in  the  present  case  is  the  intensity  of  the  jaundice 
without  variation  in  six  weeks,  the  absence  of  colic,  and  the  ])resencc  of 
a  mass  in  the  region  of  the  gall-bladder.  Long-standing  jaundice  due 
to  gall-stones  is  usually  associated  with  a  normal  sized  or  contracted 
gall-bladder  (Courvoisier's  law).  It  is  quite  possible,  however,  that 
the  mass  in  the  region  of  the  gall-bladder  is  not  due  to  distention  of  that 
viscus. 

Cirrhosis  almost  never  produces  an  intense  degree  of  jaundice.  The 
coloration  is  slight  or  moderate.  It  is  rarely  associated  with  pain,  and 
usually  produces  either  enlargement  of  the  liver  or  some  eN'idence  of 
portal  stasis. 

Cancer  then  seems  the  more  likely  diagnosis;  whether  it  is  of  the 
pancreas  or  the  bile-ducts  we  have  no  means  of  determining.  That  it 
is  probably  not  in  the  liver  itself  is  to  be  argued  from  the  absence  of  gastric 
symptoms  and  of  ol^jective  manifestations  of  gastric  disease. 

Outcome. — Operation,  April  23d,  showed  moderate  enlargement 
of  the  liver,  distention  of  the  gall-bladder,  and  a  mass  of  hard,  apparently 
cancerous,  tissue  in  the  region  of  the  pancreas.  The  patient  made  a  good 
recovery  from  the  operation. 

Diagnosis. — Pancreatic  cancer;  [chronic  pancreatitis]. 

Case  88 

A  chef  of  thirty-two  entered  the  hos])ital  on  April  8th  with  the  state- 
ment that  his  mother  had  died  of  a  "complication  of  diseases'';  his 
father  had  had  a  persistent  cough  for  four  years;  one  l:)rother  had  died 
of  consumption  at  the  age  of  twenty-four,  and  a  sister  died  of  ''rectal 
abscess"  at  the  same  age.  The  patient  had  Ijcen  exposed  to  tubercu- 
losis. 

EN'cr  since  he  was  nineteen  years  of  age  he  has  had  attacks  called  e])i- 
lepsy.  Hiese  have  always  come  during  slcej),  and  do  not  awaken  him.  In 
the  morning  he  wakes  with  a  headache  and  general  ])ains,  usually  finding 
that  he  has  l)itten  his  tongue.  At  lirst  these  attacks  came  a])out  once  a 
month;  now  they  come  onlv  about  once  in  six  months.  Xc\ertheles?.  he 
was  well  and  strong  until  four  years  ago,  wlu-n  he  Aoinited  about  four 
quarts  of  tluid.  Following  this  he  was  sent  to  a  liospital  for  tu])erculosis 
and  remained  there  six  months,  altliough,  so  far  as  he  knows,  lie  lias  ne\er 
had  a  cough  and  notliing  al)normal  has  ])een  found  in  his  lungs.  Two 
and  a  half  years  ago  he  weighed  t6o  ])oun(ls:  now  lie  wfi^'hs  1,^7  ]u)U!uls. 
His  habits  are  good. 

I'or  the  past  six  weeks  he  has  bi'en  tri'ated  for  abdominal  ]iain  not 
closelv  localized.     I'our  (la\s  ai/o  he  xoniited  a  few  times,  and  \\u>  \ omit- 


1 88  DIFFERENTIAL   DIAGNOSIS 

ing  has  persisted  and  rather  increased  since  then.  In  the  last  two  days 
he  has  vomited  up  about  two  quarts  of  dark-brown  material,  together 
with  some  food  which  he  thinks  was  eaten  at  least  twenty-four  hours 
before.  His  ])ain  is  now  nwst  severe  in  the  epigastrium  and  under  both 
costal  margins.  It  is  sometimes  relieved  by  vomiting,  and  is  never 
worse  after  eating.  Yesterday  he  noticed  palpitation  for  the  first  time. 
He  has  a  good  appetite,  but  has  had  some  constipation  for  three  weeks. 

Physical  examination  was  negative  except  for  slight  tenderness  in  the 
left  epigastrium  and  under  both  costal  margins.  His  vomitus  was  found 
to  contain  free  hydrochloric  acid,  and  the  guaiac  test  was  positive,  both 
in  the  stomach-contents  and  in  the  stool.  Despite  careful  diet,  he  con- 
tinued to  vomit  and  have  pain. 

Discussion. — Abdominal  symptoms  of  any  kind,  when  occurring  in 
a  patient  with  so  strong  a  tuberculous  history,  compel  us  to  make  a 
most  searching  examination  for  evidences  of  tuberculous  peritonitis. 
This  is  true  e\'en  when  the  onset  is  much  more  acute  than  in  this  case.^ 
But  in  the  absence  of  fever  and  of  all  the  local  manifestations  of  tubercu- 
lous peritonitis  (free  fluid,  generalized  tenderness,  spasm,  and  tumor- 
like masses)  this  disease  may  be  excluded. 

Is  it  possible  to  connect  in  any  way  the  history  of  epileptiform 
attacks  with  the  present  symptoms?  Such  attacks  might  be  due  to 
cerebral  syphilis,  and  the  same  disease  attacking  the  \\\er  and  spleen 
might  now  produce  acute  abdominal  pain.  But  in  the  absence  of 
any  enlargement  of  the  liver  or  spleen,  and  without  fever,  anemia,  or 
other  lesions  pointing  to  syphilis,  we  have  no  good  reason  for  consider- 
ing this  disease  seriously. 

In  the  treatment  of  cases  characterized  by  pain  and  vomiting  I  have 
often  been  misled  so  as  to  forget  the  possibility  of  chronic  intestinal  ob- 
struction— misled,  I  mean,  by  the  prominence  of  symptoms  apparently 
referable  to  the  stomach.  Especially  when  there  is  constipation,  as  in 
the  present  case,  this  possibility  should  never  be  lost  sight  of;  but  it  must 
remain  a  mere  possibility  unless  there  is  other  evidence  to  support  it. 
In  the  present  case  the  positive  guaiac  test  in  the  stool  is  all  that  we 
have  in  the  way  of  physical  signs  favoring  obstruction.  In  the  absence 
of  tumor,  visible  peristalsis  or  intestinal  noise,  chronic  obstruction  de- 
serves no   further   consideration. 

If,  then,  tlie  symptoms  are  of  gastric  origin,  as  seems,  on  the  whole, 
most  probable,  there  are  but  two  diseases  deserving  serious  considera- 
tion— cancer  and  ulcer.  In  the  absence  of  alcoholism  and  of  any  other 
cause  for  chronic  congestion  of  the  stomach   (heart  disease,  cirrhosis), 

^  As  an  illustration  of  the  acute  onset  of  symptoms  in  tuberculous  peritonitis  see  p.  427. 


EPIGASTRIC    PAIN  1 89 

cancer  and  ulcer  are  the  only  diseases  likely  to  produce  hemorrhage  both 
from  the  stomach  and  the  bowel,  associated  with  persistent  vomiting 
and  epigastric  pain.  This  likelihood  is  increased  when  the  patient  fails 
to  improve  after  careful  dieting. 

Against  cancer  is  the  fact  that  the  patient  is  relatively  young,  has  no 
steady  gastric  stasis,  and  especially  the  persistence  of  a  good  appetite. 
The  presence  of  free  hydrochloric  acid  is  also  somewhat  against  the  diag- 
nosis of  cancer.  On  the  whole,  peptic  ulcer,  gastric  or  duodenal,  is  the 
best  working  diagnosis. 

Outcome. — On  the  fifteenth  of  May  his  stomach  was  opened  and  a 
puckered  scar  found  on  the  posterior  wall  of  the  stomach.  Posterior 
gastro-enterotomy  was  done.     The  patient  did  well. 

Diagnosis. — Gastric  ulcer. 

Case  89 

A  waitress  of  twenty-eight  entered  the  hospital  on  May  5,  1898. 
She  said  that  she  had  "malaria  of  the  stomach"  seven  years  ago,  and 
was  sick  for  three  days  with  fever  and  chills.  At  that  time  she  had  no 
vomiting  and  no  pain,  and  has  otherwise  been  well  except  for  occasional 
"chills,"  until  three  years  ago,  when  she  began  to  have  a  gnawing  in  the 
stomach,  coming  immediately  after  eating  and  followed  ])y  gastric 
distention  and  belching,  which  continues  until  about  two  hours  after 
eating.  This  belching  has  been  worse  for  the  past  year.  At  times 
enormous  quantities  of  gas  are  expelled  with  much  noise.  For  relief 
from  the  gnawing  sensation  she  sometimes  makes  herself  vomit,  the 
vomitus  usually  consisting  of  about  half  a  pint  of  white  phlegm  in  which 
she  has  several  times  seen  specks  of  blood.  Her  appetite  has  been  good 
and  her  bowels  regular. 

Physical  examination  shows  a  very  marked  pulsation  near  the  navel; 
over  it  a  thrill  is  felt  and  a  systolic  murmur  heard.  There  is  slight  ten- 
derness in  the  center  of  the  epigastrium.  The  examination  revealed 
nothing  abnormal. 

The  guaiac  test  in  the  stool  was  negative.  She  was  put  on  a  diet  of 
carbohydrate  and  fats,  with  a  diagnosis  of  gastric  neurosis,  and  was  at 
once  rclie\"ed  of  her  sym])toms. 

Discussion. — Any  one  who  had  the  opportunity  to  hear  the  thunder- 
ous noise  with  wliich  this  ])atient  expelled  gas  from  the  stomach  would  be 
strongly  biased,  T  think,  toward  a  diagnosis  of  gastric  neurosis,  tor 
these  ex|)losions  arc  almost  always  preceded  and  l)rouglit  about  1>\-  tlie 
hal)il  of  ''cribbing,"  or  swallowing  air,  which  in  turn  is  usually  thf  result 
of  gastric  neurosis.     The  most  important  (|uestion  is,  can  we  (.xclude  ju-p- 


ipo 


DIFFERENTIAL   DIAGNOSIS 


tic  ulcer?  Many  of  the  symptoms  suggest  this  disease,  and  the  patient's 
neurotic  constitution  by  no  means  excludes  it.  On  the  other  hand,  it 
is  unusual  for  the  patient  to  be  relieved  of  pain  and  other  gastric  symptoms 
at  a  time  when  the  stomach  is  empty.  Though  many  gastric  ulcers  exist 
without  producing  hemorrhages,  it  would  be  impossible,  I  think,  to  make 
a  diagnosis  of  ulcer  in  this  case  unless  hemorrhage  occurred.  The 
specks  of  blood  in  the  ^'omitus  are,  of  course,  of  no  special  importance, 
and  the  epigastric  tenderness  has  no  diagnostic  value. 

The  thought  of  aneurysm  is  apt  to  disturb  both  doctor  and  patient, 
when,  as  in  the  present  case,  abdominal  pain  is  associated  with  a  marked 
pulsation,  palpable  thrill,  and  systolic  murmur  near  the  navel.  The 
evidences  by  means  of  which  aneurysm  may  be  excluded  in  this  and 
similar  cases  have  already  been  fully  discussed  on  p.  142.  ]\Ialaria  was 
considered  in  the  diagnosis  of  this  case,  but  a  careful  temperature 
record  enabled  us  to  exclude  it.  The  diagnosis  remained  in  doubt, 
gastric  ulcer  and  gastric  neurosis  being  the  main  alternatives. 

Outcome. — On  June  6th  she  was  once  more  on  house  diet,  up  and 
about  the  ward,  and  seemingly  quite  well.  With  care  about  diet  and  an 
improved  environment,  the  patient  has  continued  well  up  to  the  present 
time  (1910). 

The  continued  good  health,  after  so  short  a  period  of  treatment,  seems 
to  me  to  argue  strongly  against  ulcer. 

Diagnosis. — Gastric  neurosis. 

Case  90 

A  Jewess  of  thirty  had  been  operated  on,  July  30,  1900,  for  cholecys- 
titis. The  gall-bladder  was  drained.  After  this  operation  she  re- 
mained well,  and  has  had  three  children.  She  entered  the  hospital 
March  13,  1907,  complaining  of  epigastric  pain  of  two  years'  duration, 
coming  at  irregular  intervals,  and  worse  after  eating.  For  the  past 
month  the  pain  has  increased  in  severity  and  has  radiated  to  the  back, 
but  not  to  either  side;  it  often  awakens  her  at  night.  Her  bowels  are 
constipated,  and  she  has  eaten  litde  for  the  past  four  weeks,  though  her 
appetite  was  previously  good.  She  has  lost  much  strength,  and  for  the 
past  four  days  has  remained  in  bed. 

At  entrance  and  thereafter  her  pulse  ranged  most  of  the  time  above 
90,  and  not  infrequently  reached  120.  Her  evening  temperature  was 
usually  above  99°  F.,  but  below  100°  F. 

Physical  examination  showed  nothing  abnormal  in  the  chest.  There 
was  general   abdominal  rigidity,  especially  above  the  navel,  where  there 


EPIGASTRIC   PAIN 


191 


was  marked  diffuse  tenderness.  The  white  cells  were  27,000  at  entrance, 
and  88  per  cent,  of  these  cells  were  polynuclear.  Three  days  later  the 
tenderness  was  gone,  and  the  leukocytes  were  found  to  be  normal;  they 
remained  so  thereafter.     The  urine  was  at  all  times  negative. 

Examination  of  vomitus  showed  free  hydrochloric  acid  in  abundance, 
and  a  positive  guaiac  test  for  blood  was  obtained.  Tube  examination 
was  negative.  In  the  stool  the  guaiac  test  was  twice  negative.  The 
patient  complained  of  marked  abdominal  pain,  but  obtained  great 
relief  from  the  subcutaneous  injection  of  sterile  water. 

The  patient  was  treated  by  careful  feeding,  the  administration  of 
l^-grain  doses  of  cocain,  and  dram-doses  of  Hoffmann's  anodyne  for 
gastric  distress.  On  one  or  two  occasions  I  grain  of  morphin  was 
administered.  Nutrient  enemata  were  tried,  but  were  always  expelled 
within  a  short  time.  The  patient  took  liquids  well  after  the  first  few 
days  and  was,  for  the  most  part,  free  from  pain  and  vomiting. 

Discussion. — The  symptoms  seem  to  be  very  much  the  same  as 
those  previously  proved  to  be  due  to  cholecystitis.  Since  the  gall- 
bladder was  drained,  and  probably,  for  the  most  part,  obliterated,  it  is 
unlikely  that  there  is  any  return  of  inflammation  at  that  point,  especially 
as  she  seems  to  have  had  five  years  of  freedom  from  symptoms.  The 
same  considerations,  however,  lead  us  to  wonder  whether  adhesions 
may  not  have  formed  in  the  vicinity  of  the  gall-bladder,  resulting  in 
gastric  stasis  and  ])recipitating  the  attacks  of  pain.  The  absence  of 
any  gastric  stasis,  however,  as  evidenced  by  the  stomach-tube  examina- 
tion, makes  this  supposition  less  likely. 

The  local  signs  at  the  time  of  entrance  and  the  leukocytosis  point 
rather  toward  a  local  peritonitis,  possibly  from  a  gastric  ulcer.  Were  this 
the  case,  however,  we  should  not  expect  the  disappearance  of  all  these 
signs  within  three  days.  One  cannot  help  being  influenced  by  the  fact 
that  this  ])atient's  j)ain  was  greatly  impro^"cd  by  the  "  lie  cure  ''  (injec- 
tions of  sterile  water,  mistaken  by  the  patient  for  mor])hin). 

Chronic  ap])endicitis  has  not  been  yet  extensively  discussed  in  this 
book,  for  the  reason  that  I  fmd  it  hard  to  arri\e  at  any  Acry  definite 
conclusion  upon  the  su])ject,  l)ut  certainly  this  case  is  very  similar  to 
those  which  surgeons  are  accustomed  to  operate  on  with  that  diagnosis. 
The  childhood  attacks  often  seen  in  chronic  appendicitis  are  not  here 
mentioned.  Inhere  was  at  no  time  any  local  tenderness  or  spasm  in  the 
right  iliac  region,  nor  any  radiation  of  ])ain  to  that  region.  Xcxcrthclrss. 
it  is  certainly  true  that  cases  no  more  typical  than  this  ha\e  l)c'en  rtlirxcd 
of  all  symptoms  after  the  remo\al  of  an  adlu-rcnt,  kinkrd  appendix. 
In  this  connection  1  wish  to  call  attention  to  the  followinLi;  tal)le,  w  hich 


192 


DIFFERENTIAL   DIAGNOSIS 


embodies  the  conclusions  of  Drs.  Graham  and  Guthrie,^  arrived  at  after 
the  study  of  a  large  series  of  cases  from  the  Mayos  clinic: 

DIFFERENTIAL  DIAGNOSIS  OF  THE  MILDER  TYPES  OF  CHRONIC 
APPENDICITIS,  PEPTIC  ULCER,  AND  GALL-STONES.— (.4 /^r  Graham 
and  Guthrie,  Jour.  Amer.  Med.  Assoc,  March  19,  1910.) 


Disease. 


•  Child- 1  Sequence 

^^I'l  hood  I  at  regular 

^    j    at-        interval 

^      i  tacks. 'after  food. 


Severity  of 
digestive 
disturb- 
ance. 


Mode  of 
relief. 


Radiations 
of  pain. 


Chronic          appendicitis     34       + 
(dyspeptic  type) 

i 
Gall-stones 40   i     o 


Peptic  ulcer 45 


Tempera- 
ment. 


Consider-  i By     pass- To     right^Neurotic. 

able.         age  of  gas    iliac     re-l 

I  or  feces,      gion.         I 

Mild.  Sudden —  To    back,!  o 

often    by    right  ax-i 

morphin.    ilia,    and 


+  + 


Moderate   By  food, 
in  early       soda, 


right 
shoulder. 


stages. 


vomiting, 
or  irriga- 


The  conclusions  of  these  observers  are  borne  out  by  most  of  my 
observations,  and  seem  to  me  about  as  near  to  wisdom  as  any  yet  offered 
upon  the  subject. 

After  very  careful  study  of  the  case  we  were  unable  to  arrive  at  any 
definite  diagnosis.  We  could  not  definitely  incriminate  the  stomach, 
the  gall-bladder,  or  any  other  viscus,  yet  we  were  by  no  means  certain 
of  the  absence  of  severe  disease  calling  for  surgical  interference.  Ac- 
cordingly, on  March  24th  the  abdomen  was  opened,  but  careful  search 
revealed  no  disease  of  any  kind.  The  patient  made  an  une\'entful 
recovery. 

Diagnosis. — Gastric  neurosis. 

Case  91 

A  dressmaker  of  twenty-three,  whose  mother  died  of  cancer  of  the 
stomach,  was  seen  January  28,  1907.  She  admitted  that  for  a  year 
she  had  taken  a  great  deal  of  beer,  ^^•ine,  and  whisky,  and  for  the  past 
two  weeks  she  had  taken  from  a  pint  to  five  pints  of  whisky  a  day. 
During  this  last  period  she  had  eaten  practically  nothing,  and  has 
been  in  bed  most  of  the  time.  A  few  days  ago,  whenever  she  closed 
her  eyes,  she  saw  big  animals  and  other  apparitions.  For  the  past  three 
days  she  has  vomited  almost  constantly,  and  had  some  epigastric  pain, 
which  has  become  more  se^•ere  during  the  past  two  days,  especially 

^  Jour.  Amer.  INIed.  .\ssoc.,  March  19,  19 10. 


EPIGASTRIC    PAIN 


f93 


when  she  breathes  deeply.  Last  night  her  respiration  was  very  difficult 
and  shallow  in  consequence.  There  has  never  been  any  blood  in  the 
vomitus. 

Temperature,  pulse,  and  respiration  were  normal,  the  left  pupil 
considerably  larger  than  the  right,  but  both  reacted  normally;  a  hea\y 
brownish  coat  was  found  on  the  tongue,  and  a  marked  tremor  in  the 
fingers.  The  chest  showed  nothing  abnormal.  The  abdomen  was 
rigid  and  tender  throughout;  exquisitely  so  in  the  epigastrium.  Liver 
dulness  was  not  increased,  and  there  was  no  shifting  dulness  in  the 
flanks. 

Discussion. — The  chief  problem  in  this  case  is  to  decide  whether  the 
alcoholism  from  which  she  is  suffering  will  account  for  all  the  symptoms. 
We  are  not  accustomed  to  associate  extreme  abdominal  tenderness  and 
rigidity  with  delirium  tremens  or  with  simple  alcoholism.  On  the 
other  hand,  if  perforative  peritonitis  (stomach,  gall-bladder,  appendix) 
were  present,  there  should  be  some  rise  of  temperature,  pulse,  respira- 
tion, or  leukocyte  count,  none  of  which  occurred.  There  is  nothing  in 
the  case  to  justify  the  suspicion  of  lead-poisoning,  tabes,  chronic  intestinal 
obstruction,  passive  congestion  of  the  liver,  pericarditis,  pneumonia,  or 
any  of  the  other  causes  of  epigastric  pain  which  have  been  discussed  on 
])rcvious  pages. 

Is  it  possible  that  the  symptoms  may  be  due  merel}'  to  the  excessive 
vomiting,  with  the  wrenching  strain  thereby  brought  upon  the  abdominal 
muscles?  ^\'e  decided  to  take  our  chance  of  this  diagnosis,  and  planned 
our  treatment  accordingly. 

Outcome. — The  next  day  the  pain  was  much  less,  likewise  the  ten- 
derness and  tremor,  and  there  has  been  no  vomiting.  B}-  February  3d 
she  was  entirely  free  from  complaints,  and  on  the  sixteenth  she  left  the 
hospital  well. 

Her  treatment  consisted  of  milk  diluted  one-third  witli  lime-water, 
4  ounces  every  two  hours  when  awake;  orthoform,  10  grains,  every  four 
hours;  hot  stupes  to  tlie  abdomen  every  hour  when  awake;  whisky,  \ 
oimce  every  four  hours;  triple  bromids,  30  grains,  and  tincture  of  cap- 
sicum, 15  minims  before  meals.  After  the  first  two  days  the  whisky  was 
omitted.     The  other  medicines  were  not  needed  after  the  thirteenth. 

Diagnosis. — Alcoholism. 

Case  92 

A  teamster  of  forty-eigiit  entered  tlie  hosjntal  August  i2tli.  Gas- 
tric ulcer  and  alxlominal  aneurysm  were  the  diagnoses  siiL^uc^kd  !iy 
the   out-]xitic'nt    physician.     The   family    history   was   not    reniarkal)le, 


194  DTFFERENTIAL   DIAGNOSIS 

except  that  one  sister  has  been  in  the  Worcester  Insane  Asylum.  The 
patient's  habits  and  past  history  are  good.  Ten  weeks  ago  he  began  to 
have  steady  ejiigastric  pain,  usually  dull,  sometimes  sharp.  After  two 
or  three  days  he  had  to  give  up  \\-ork  on  account  of  pain  and  weakness, 
but  he  has  not  been  in  bed  for  the  whole  of  any  day.  Previous  to  this 
illness  he  has  never  had  pain  of  this  sort.  It  is  v.'orst  about  one  hour 
after  eating,  but  it  is  not  relieved  by  food,  and  does  not  radiate  to  any 
other  point.  During  the  same  period  he  has  also  had  aches  and  darting 
pains  in  his  neck,  legs,  and  the  right  side  of  his  chest.  For  the  past 
two  or  three  \\  eeks  he  has  felt  sleepy  and  ner\"ous  in  the  daytime,  while 
at  night  pain  and  nervousness  have  often  kept  him  awake.  He  has 
headache  during  most  of  every  morning.  The  last  four  or  five  weeks  he 
has  been  short  of  breath,  but  has  noticed  no  s^^■elling  of  his  feet.  His 
bowels  move  only  once  in  four  days.  His  appetite  is  poor,  but  he  has 
not  vomited. 

On  examination  he  seems  to  be  emaciated.  The  chest  shows  noth- 
ing abnormal.  The  abdomen  is  decidedly  concave  and  somewhat  tender 
in  the  epigastrium,  where  there  is  marked  pulsation  visible  and  palpable 
from  a  point  two  inches  below  the  sternum  to  a  point  one  inch  below  the 
na\'el.  Otherwise  physical  examination  is  negatiA'e,  and  the  blood,  urine, 
and  temj^erature-chart  indicate  nothing  abnormal.  Tlie  patient  was 
depressed,  seemed  very  apathetic,  and  at  times  refused  nourishment. 
The  stomach-tube  proved  that  the  stomach  held  30  ounces  of  water  and 
showed  no  e\'idence  of  enlargement.  After  a  test-meal  the  extracted  con- 
tents showed  free  HCl,  0.12  per  cent.,  no  lactic  acid,  no  blood. 

Discussion. — Although  abdominal  aneurysm  was  considered  in 
this  case,  the  ]jhysical  signs  are  clearly  those  of  dynamic  aorta,  the  differ- 
ential diagnosis  of  which  has  been  already  discussed.     (See  p.  142.) 

Gastric  cancer  is  always  a  threatening  possibility  when  a  man  of 
forty-eight  begins  to  have  digestive  sym])toms  for  the  first  time  in  his 
life.  The  emaciation  present  in  this  case  lends  support  to  this  hypothesis, 
and  the  negative  results  of  examination  by  the  stomach-tube  do  not  en- 
able us  positi\"ely  to  exclude  cancer.  We  will  return  to  the  discussion  of 
it  ])elov\'. 

Peptic  ulcer  does  not  cause  pains  so  wide-spread  as  those  here  de- 
scribed. If  this  were  the  diagnosis,  we  should  exj^ect  also  some  reh'ef 
after  food,  and  \-ery  possiljly  some  Ijlood  in  the  stomacli-contents.  Yet 
while  ulcer  \vould  not  account  for  all  the  facts  here  ])resent,  we  must  hold 
judgment  in  reserve  regarding  it,  as  we  have  already  done  regarding 
cancer. 

Could  the  sym]>toms  Ijc  cxjjlained  as  the  result  of  simple  constipa- 


EPIGASTRIC    PAIN  I95 

tion  combined  with  starvation  which  his  emaciation  suggests?-"  Very 
possibly  they  may,  but  we  still  require  some  reason  for  the  sudden  appear- 
ance of  constipation  in  a  healthy  teamster  of  forty-eight. 

We  cannot  afford  to  leave  out  of  consideration  the  ps}-chic  symptoms 
in  this  case.  A  middle-aged  laboring-man  does  not  Ijcgin  to  Ix;  sleep- 
less and  nervous  without  obvious  cause.  The  ordinary  cause  for  such 
symptoms  is  alcoholism,  which  could  be  defmitcly  excluded  here.  In 
view  of  the  patient's  depression,  his  ])ersistent  headaches,  his  nervous- 
ness, insomnia,  and  apath}-,  a  mild  t}])e  of  insanity  (depressive  maniac 
psychosis)  seems  probable,  especially  since  no  cause  for  his  depression 
can  be  found  in  any  of  the  recent  events  of  his  life.  Assuming  this  to 
be  true,  the  (picstion  remains:  Can  the  abdominal  symptoms,  the  ano- 
rexia, and  emaciation  be  thus  explained?  To  this  it  is  to  be  ans\\'ered 
that  in  sanatoria  and  asylums  for  the  insane  it  is  a  very  common  ex- 
perience to  find  the  foreground  of  the  clinical  ])icture  occupied  mainly  by 
gastro-intestinal  symptoms  almost  as  severe  as  those  seen  in  organic 
disease.  The  further  course  of  these  cases,  however,  demonstrates  the 
absence  of  any  such  disease,  and  leads  us  to  the  conclusion  that  tlie 
gastro-intestinal  symi)toms  are  simply  one  item  in  the  s}-mptom-com]>lex 
called  insanity. 

Assuming  then  that  this  patient  is  mildly  insane,  we  are  justified  in 
supposing  that  his  stomach  symptoms  are  dependent  upon  this  ])s\chosis, 
e\en  though,  were  he  normal  mentally,  we  sliould  be  strongly  inclined  to 
bclie\e  that  he  had  gastric  ulcer  or  cancer. 

Outcome. — The  ])atient  became  more  and  more  de])ressed.  7'\\o 
s])ecial  consultants  pronounced  the  case  simple  melancholia,  and  he  was 
removed  to  an  asylum. 

Diagnosis. — Melancholia. 

Case  93 

An  Italian  laborer  fortv  years  old  had  "rheumatism"  fwc  years  ago 
and  one  year  ago.  Many  joints  were  swollen,  painful,  and  tcn(Lr  tor 
a  few  weeks  in  each  attack,  but  he  has  regained  ]K'rfect  function  in  all 
the  joints. 

He  takes  two  whiskies  b(;fore  breakfast  and  four  l)eers  during  the 
day.     Denies  N'enereal  disease. 

For  six  weeks  he  has  had  gna\Ning  i)ain  in  tlu>  ei)igastrium  nv.d  ri'.'l.i 
hvpochondrium,  gradually  getting  worse,  soun'times  (listurliinu'  >le(;'. 
but  never  inilueneed  l)\-  food.     Xoeturia,  t  to   :;  times. 

l^hysiral  hlxani'niiUion-  The  eardiat'  iiuimlse  exteiid>  1  em.  n'.iKidi- 
the  nip])le  in  the  fifth  space.     \o  enlargcLnent  to  tlie  riL^lit  is  dr'.ccted. 


196  DIFFERENTIAL   DIAGNOSIS 

Cardiac  action  regular — 80  per  minute;  the  apex  first  sound  is  replaced 
by  a  long,  blowing  murmur,  which  is  also  audible  in  the  left  axilla.  At 
the  third  left  costal  cartilage  is  the  maximum  intensity  of  a  diastolic 
murmur,  which  is  also  faintly  heard  in  the  second  right  interspace.  The 
pulmonic  second  sound  is  accentuated. 

All  the  superficial  arteries  pulsate  strongly,  and  there  is  a  "Corrigan" 
and  capillary  pulse. 

Nails  slightly  incurved.     Lungs  negative. 

In  the  uj^per  right  abdominal  quadrant  is  a  mass  easily  felt  bimanu- 
ally,  descending  over  an  inch  on  full  inspiration,  with  a  rounded  edge 
and  a  semifluctuant  consistence.  The  liver  dulness  extends  8.5  cm. 
below  the  ribs  (nipple-line)  and  12.5  cm.  below  the  ensiform.  Whether 
or  not  the  liver  is  continuous  with  the  mass  described  above  cannot  be 
certainly  determined.  The  liver  edge  is  sharp  on  the  left  of  the  median 
line,  but  cannot  be  felt  distinctly  on  the  right. 

The  spleen  is  palpable  2  cm.  below  the  ribs.  Abdomen  otherwise 
negative;  likewise  the  rest  of  the  body.  Urine,  40  ounces;  specific  grav- 
ity, 1021.    No  albumin,  pus,  blood,  or  casts.     Blood  normal. 

Cystoscopy  showed  evidence  of  normal  functioning  in  each  kidney. 

Discussion. — Clearly  enough  this  patient  has  incompetence  of  the 
aortic  and  mitral  valves,  presumably  of  rheumatic  origin.  The  inter- 
esting problem  remaining  concerns  the  mass  in  the  right  hypochondrium. 
Is  it  liver,  kidney,  or  retroperitoneal  tumor? 

The  alcoholic  history  may  have  produced  a  cirrhosis,  but  cirrhosis 
rarely  causes  pain,  and  the  cirrhotic  liver  is  hard,  not  semifluctuant. 
Moreover,  we  do  not  expect  to  feel  the  liver  bimanually,  though  that  is 
by  no  means  impossible.  There  seems  reason  to  belie^'e  that  the  li\'er 
is  enlarged  in  this  case,  but  apparently  there  is  something  else  wrong. 

A  mass  ])alpable  bimanually  in  the  right  flank  usually  turns  out  to  be 
connected  with  the  kidney,  and  it  was  with  this  in  mind  that  cystoscopy 
was  done.  The  results  of  tliis  examination  go  far  toward  excluding 
renal  disease,  and  were  interpreted  in  this  sense. 

Tumors  of  the  retroperitoneal  glands  produce  not  infrequently  a 
mass  like  that  here  descril^ed.  Diagnosis  of  such  tumors,  however,  is 
impossible  imless  there  are  more  definite  pressure  symptoms  (pain  in  the 
back  and  legs),  or  unless  there  has  been  malignant  disease  elsewhere  in 
the  body,  with  possible  metastasis  in  the  region  now  under  considera- 
tion. 

S}'philis  of  the  li\'er  and  cancer  of  the  liver  or  colon  would  not  account 
for  so  soft  a  mass  as  is  here  described.  Is  it  possible  that  sim])lc  ])assive 
congestion  due  to  the  cardiac  lesion  might  produce  so  soft  an  enlarge- 


EPIGASTRIC   PAIN 


[97 


ment  of  the  liver?  Against  this  is  the  absence  of  much  stasis  in  the  lungs, 
legs,  or  abdominal  cavities,  and  the  fact  that  the  questionable  mass  can- 
not with  certainty  be  connected  with  the  liver  edge  palpable  to  the  left  of 
the  median  line.  A  surgical  consultant  considered  the  symptoms  due 
to  a  tumor  of  the  gall-bladder  or  of  the  kidney.  On  the  whole,  there 
seems  to  be  enough  doubt  upon  this  point  to  justify  exploratory  lapa- 
rotomy. 

Outcome. — Laparotomy  showed  the  kidneys  and  gall-bladder  to  be 
normal.     A  large,  dark,  congested  liver  was  tJie  only  finding. 

This  case  seems  to  me  to  be  of  unusual  interest,  since  it  shows  that 
passive  congestion  of  the  liver  is  one  of  the  items  which  must  be  seriously 
considered  in  a  diagnosis  of  diseases  involving  the  right  upper  quadrant. 
So  far  as  I  am  aware,  this  is  one  of  the  few  cases  on  record  in  which 
laparotomy  has  been  done  for  passive  congestion  of  the  liver. 

Diagnosis. — Hepatic  congestion. 

Case  94 

A  private  secretary,  sixty  years  old,  entered  the  hospital  March  2, 
1907.  Her  father  died  of  consumption.  She  had  diphtheria  at  twelve. 
Twenty-five  years  ago  she  had  inflammatory  rheumatism  and  ophthalmia, 
was  in  bed  a  week,  and  has  had  a  slight  similar  attack  since.  In  the  past 
thirty  years  she  has  had  about  twelve  attacks  of  colic,  characterized  by 
sudden  painful  cramps  in  the  abdomen.  The  last  attack  was  in  July, 
1906.  Ten  years  ago  an  appendix  aljsccss  was  opened  and  drained.  She 
has  ne\'er  been  jaundiced,  but  always  has  had  a  strong  tendency  to  con- 
stipation. Her  best  weight  \\  as  182  pounds  six  months  ago.  Six  weeks 
ago  she  had  several  attacks  of  indigestion  within  a  week;  after  this  she 
was  well  until  four  weeks  ago,  when  she  had  a  sudden  severe  attack  of 
e])igastric  pain  lasting  an  hour.  She  has  had  five  or  six  similar  attacks 
since,  most  of  tlieni  coming  after  l)reakfast  and  lasting  se\eral  liours  until 
relieved  l)y  mor])hin. 

The  pain  does  not  seem  to  radiate  in  any  direction.  For  three  days 
she  lias  been  jaundiced. 

Physical  examination  sliowed  an  ol)esity  and  a  marked  jauiidicc. 
but  was  otherwise  negati\-e.  Bv  the  sixlh  of  Marcli  the  jaundice  had 
cleared  up  and  the  ])atient  was  comfortabk'  except  for  shght  sore  tliroat. 

Discussion. — Since  tuljerculous  ])crit()nitis  may  manifest  itsclt  toi- 
tlie  first  time  witli  svm])toms  as  acute  as  those  hcxv  ])r('sc'nt,  it  docrws 
a  moment's  consideratioii,  es])cciall\'  in  \"iew  of  tlic  tul)erculous  lainily 
history.  ?)iit  there  are  no  ])h\-sical  signs  corrcsiiondini:  t(^  lliis  (h^case, 
and  in  the  a])sence  of  fe\er  it  need  not  be  fiirtlicr  disc-iis-^id. 


198 


DIFFERENTIAL   DIAGNOSIS 


Attacks  of  abdominal  pain  in  a  patient  who  has  no  knee-jerks  should 
always  remind  us  of  tabes,  yet  there  are  no  other  confirmatory  facts, 
and  it  is  quite  possible  that  the  diphtheria  which  the  patient  passed 
through  at  the  age  of  twelve  may  have  produced  a  neuritis  which 
accounts  for  the  loss  of  knee-jerks. 

In  elderly  persons  with  a  strong  tendency  to  constipation  we  need 
no  further  explanation  for  many  uncomfortable  abdominal  symptoms; 
but  constipation  practically  never  produces  pain  so  sharp  as  to  require 
morphin  imless,  indeed,  it  be  due  to  organic  obstruction.  Her  age  and 
the  character  of  the  pain  are  quite  consistent  with  this  diagnosis,  and 
experience  has  shown  that  intestinal  obstruction  is  always  a  serious 
danger  for  those  who  have  been  operated  upon  for  appendicitis,  especi- 
ally if  the  formation  of  adhesions  has  been  favored  by  drainage  of  the 
wound.  But  if  the  intestine  were  obstructed,  we  should  expect  disten- 
tion and  \'omiting,  while  the  attacks  of  pain  would  probably  not  occur 
so  frequently  and  at  such  short  intervals. 

Peptic  ulcer  is,  as  in  so  many  cases,  a  possibility  impossible  to  exclude, 
but  the  presence  of  jaundice,  the  sudden  relief  by  morphin,  and  the 
absence  of  any  definite  relation  between  the  pain  and  the  taking  of  food 
turn  our  attention  rather  to  gall-stones.  Since  the  appearance  of  the 
jaundice  this  diagnosis  has  l^een  tolerably  ob^■ious.  It  is  favored  by 
the  age  and  sex,  the  obesity,  and  the  character  of  the  pain. 

Outcome. — -The  abdomen  was  opened  on  the  ninth  of  ]\Iarch,  and 
showed  a  small  gall-bladder  completely  filled  with  stones. 

Diagnosis. — Gall-stones. 

Case  95 

Mrs.  H.,  a  widow  of  seventy,  was  seen  in  consultation  No^•ember 
8,  1901.  Her  mother  died  of  old  age  at  eighty-one;  her  father  of  dia- 
betes at  sixty.  Three  sisters  died  of  pulmonary  tuberculosis;  one  from 
an  accident;   one  of  unknown  cause;   one  is  still  living. 

Mrs.  H.  has  had  ten  children:  By  first  husband,  eight;  two  of  these 
died  of  pulmonary  tuberculosis,  one  of  "dropsy";  one  daughter  died 
from  "effects  of  a  surgical  operation";  three  died  in  infancy,  cause 
unknown;  one  li\ing.  The  two  children  In*  her  second  hus1)and  are 
living  and  well. 

She  had  the  usual  children's  diseases,  but  otherwise  was  always 
well  until  1890,  when  she  had  strangulated  hernia  and  was  operated 
upon.  During  the  following  year  she  did  not  feel  well,  had  fe\"er, 
chills,  \omiting,  and  pain,  and  in  1891  was  oj)erated  for  right  empyema. 
This  discharged  for  six  months,  but  finally  healed.     Since  that  time 


EPIGASTRIC    PAIN 


199 


she  has  complained  of  dyspepsia,  sour,  bitter  eructations,  dull  pain 
in  epigastrium,  headache,  malaise,  and  gradual  loss  of  flesh — about 
20  pounds  in  all. 

In  May,  1901,  she  had  an  attack  of  severe  pain  in  the  epigastrium, 
midway  between  umbilicus  and  ensiform;  the  pain  was  relie\ed  by  hot 
drinks.  A  month  later  had  a  similar  attack;  a  physician  was  called, 
who  said  it  was  acute  neuralgia  of  the  stomach.  He  gave  her  something 
to  make  her  vomit,  and  she  vomited  for  twenty-four  hours  almost  con- 
tinuously, the  vomitus  consisting  mostly  of  "green,  bitter  stuff."  She 
had  a  similar  attack  September  i,  1901,  relieved  by  hot  drinks.  There 
was  some  vomiting  in  this  attack.  Next  attack,  September  8th;  then, 
Se])tember  14th;  the  last  two  relieved  by  morphin,  \  grain.  The  final 
attiick  about  October  19th.  This  last  attack  was  the  most  severe.  Be- 
tween attacks  patient  \vas  fed  on  liquids  and  semisolids,  and  complained 
of  no  pain  or  indigestion.  The  pain  seemed  to  start  at  a  spot  in  the 
right  back  on  the  level  of  the  sixth  or  seventh  rib,  radiating  straight 
forward  to  "pit  of  stomach,"  thence  down  the  left  side  of  the  belly. 
There  was  nothing  to  be  seen  at  this  dorsal  spot,  but  it  was  painful  to 
touch.  After  receiving  a  subcutaneous  injection  of  morphin,  she  began 
to  vomit  and  continued  to  vomit  about  e^■cry  half-hour  for  thirty-six 
hours.  She  became  very  weak,  but  had  a  normal  temperature  and  a 
pulse  of  60.  She  j)asscd  bui;  little  urine  during  this  thirty-six  hours, 
but  at  the  end  of  it  she  voided  nearly  two  quarts.  Examination  of  this 
urine  showed  specific  gravity  1022,  color  high,  about  o.i  per  cent,  of  albu- 
min. Sediment  contained  few  h}aline  and  fine  granular  casts,  with  fat- 
drops  adherent.  A  specimen  of  urine  sixteen  hours  later  was  smoky,  con- 
tained 0.1  albumin,  and  in  addition  to  sediment  in  previous  urine  was 
full  of  blood  and  calcium  oxalate  crystals.  The  patient  now  complained 
of  pain  in  both  flanks  and  soreness  all  over  abdomen,  especially  on  right 
side.  The  temperature  now  is  ioc°  F.  and  pulse  88.  There  is  headache. 
Blood-pressure,  145.  No  jaundice  now  or  in  any  of  these  attacks,  ])ut 
the  patient  says  she  always  looked  a  little  yellow. 

She  is  a  well-preserved  lady,  rather  fat.  Liver  normal  in  size.  A 
point  of  extreme  tenderness  is  situated  half"\\'ay  between  ensiform  and 
umbilicus.  Heart  and  lungs  ncgatiN'e.  Colon  distended  with  gas.  'Yhv 
sclera  near  the  iris  is  clear  blue.  On  drawing  back  the  eyelid  a  sliijhl 
tinge  of  yellow  is  \isible  at  tlie  pcri{)hery. 

Discussion. — Intestinal  ol)structi()n  is  naturally  our  ln>t  tlioiiL'hl 
when  a  ])atii'nt  c()m])lains  of  acute  abdominal  symptoms  \\\\\\  jicTsistcnt 
vomiting,  and  has  previouslv  had  an  operation  for  strangulated  lu'rnia. 
But  in  this  case  there  is  no  abdominal   distention,  no  ronstiimtion  or 


200  DIFFERENTIAL   DIAGNOSIS 

diarrhea,  no  visible  peristalsis,  and  an  unusual  degree  of  comfort  between 
attacks. 

When  a  patient  is  relieved  as  markedly  as  in  this  case  by  the 
taking  of  hot  drinks,  gastric  flatulence  with  pyloric  spasm  seems  a 
natural  explanation.  But  this  symptom  in  practically  all  cases  is 
dependent  upon  some  deeper  cause,  such  as  peptic  ulcer  or  gall-stones. 
The  long  history  of  dyspepsia  leading  up  to  sharp  attacks  of  pain  is 
consistent  with  either  of  the  above  diagnoses,  which  will  be  further 
discussed  below.  One  of  the  confusing  elements  here  is  the  condition 
of  the  urine.  Can  the  symptoms  be  due  to  uremia,  which  is  traditionally 
supposed  to  lead  to  attacks  of  abdominal  pain  in  certain  cases?  The 
urine  does  not  suggest  acute  nephritis,  and  if  any  type  of  chronic  nephri- 
tis were  present,  there  should  be  hypertrophy  of  the  heart  and  a  higher 
blood-pressure.  In  all  probability,  therefore,  the  urinary  findings 
are  to  be  explained  as  the  result  of  some  toxic  irritation  of  the  kidney, 
and  are  not  of  any  serious  significance.  In  one  of  the  later  examinations 
the  presence  of  macroscopic  blood  in  the  urine  is  noteworthy  as  sug- 
gesting a  possible  stone  or  tumor  of  the  kidney,  but  one  remarks  that 
this  specimen  of  urine  was  passed  not  long  after  the  bladder  had  been 
emptied  of  two  quarts  of  urine  following  an  acute  retention.  This 
chain  of  events  is  notoriously  prone  to  produce  hematuria.  On  the 
whole,  then,  in  the  absence  of  any  palpable  mass  in  the  kidney  region, 
there  seems  no  good  reason  to  suspect  that  organ. 

We  are  left  with  the  two  diseases  so  often  suspected  and  discussed 
heretofore — gall-stones  and  peptic  ulcer.  The  tender  spot  in  the 
back  corresponds  rather  to  the  pain  of  gall-stones  than  to  tliat  of  ulcer, 
and  it  is  especially  significant  that  in  one  of  the  attacks  the  pain  started 
at  this  point  and  radiated  thence  forward.  The  immediate  relief  of 
pain  by  morphin  and  the  absence  of  indigestion  between  attacks  incline 
us  to  the  diagnosis  of  gall-stones,  especially  since  the  less  accessible 
portions  of  the  sclera  have  begun  to  show  a  yellowish  tinge. ^ 

The  prolonged  vomiting  after  the  administration  of  mor])hin  is 
])resumably  to  be  ascriljed  to  one  of  the  not  uncommon  idiosyncrasies 
in  relation  to  this  drug. 

Outcome. — Xext  day  slight  jaundice  was  evident  in  the  sclera. 
This   gradually    deepened    until   her   skin   was   almost  a  coffee  color. 

^  It  is  ]jerha])S  worth  noting  here  that  when  we  arc  expecting  or  susjiectintc  a  slight 
degree  of  jaunflice,  we  should  examine  especially  the  j:)eripheral  portions  of  the  sclera, 
which  show  a  yellowish  Un<re  long  ix-fore  there  is  anv  coloration  aronnrl  the  iris.  It  is 
only  in  the  more  pronounced  grades  of  jaundice  that  the  \-ellow  color  actually  meets  the 
iris.  Attention  to  this  pf)int  sometimes  renders  the  niore  delicate  tests  of  the  serum  un- 
necessary. 


EPIGASTRIC    PAIN  20I 

The  stools  were  carefully  sifted,  but  no  stone  found.  Liver  tender. 
In  two  days  the  gall-bladder  could  be  felt.  Urine  hea\y  with  bile; 
stool  clay  colored.  Temperature,  ioo°  to  ioi°  F.;  pulse,  80  to  icxd. 
Pain  in  both  flanks.  The  spot  on  her  back  has  developed  into  a  mark 
that  looks  as  if  some  local  application  had  been  made.  It  is  shaped 
like  this:  0?  has  sharply  defined  edges,  is  not  tender,  not  swollen,  and 
not  hot. 

Operation  showed  stones  in  the  common  duct 

Diagnosis. — Gall-stones. 


202 


DIFFERENTIAL   DIAGNOSIS 


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Causes  of  Pain  in  the  Right  Hypochondrium 


1.  PASSIVE  CONGESTION  OF  THE  UVER 


2.  GALL-STONESl 
AND    ACUTE 


CHOLECYS-]  ^^^^^^^^^^^^^^^^^^^^^^^^ 
TITIS                       J 

3.  HIGH     APPENDIX  I  ^^ 

(INFLAMED)  I  ^^ 

4.  CANCER  OF  THE  1 

LIVER  I 

5.  URETERAL   STONE  ■  15 

6.  RENAL  STONE  I  10 

7.  PEPTIC  STONE  |  9 


8.  SUBDIAPHRAGM- 
ATIC  ABSCESS 


Rarer  causes  are :    Hydro-  and   pyonephrosis,  renal  and  perirenal 
infections,  sacro-iliac  lesions,  and  retroperitoneal  neoplasms. 


2i)4: 


CHAPTER  VI 


RIGHT  HYPCXHONDRIAC  PAIN 


Case  96 


A  boy  of  twelve  entered  the  hospital  April  6,  1908,  complaining 
of  tenderness  and  pain  in  the  right  hypochondrium.  He  had  a  tempera- 
ture of  100°  F.  Gall-bladder  inflammation  was  the  diagnosis  suggested 
by  his  physician.  His  previous  and  family  history  suggested  nothing, 
but  he  had  been  suffering  almost  constantly  for  two  months  with  the 
pain  above  described.  This  pain  has  been  gradually  growing  worse, 
and  is  now  aggravated  by  deep  inspiration.  Occasionally  he  has  a 
sharp  pain  in  the  right  shoulder;  otherwise  than  this  he  has  had  no 
symptoms,  and  has  been  able  to  go  to  school  until  five  days  before  his 
entrance  to  the  hospital.  He  lias 
been  decidedly  constipated. 

Physical  examination  showed  that 
the  heart's  impulse  was  best  seen 
and  felt  in  the  fourth  interspace, 
just  outside  the  nipple-line.  The 
soimds  were  regular  and  of  good 
quality.  A  soft  systolic  murmur  was 
heard  at  the  apex,  not  transmitted 
widely;  the  pulmonic  second  sound 
was  slightly  accentuated;  the  pulse 
not  remarkable.  The  lungs  were 
normal,  likewise  the  abdomen,  with 
the  exception  of  tenderness  and  con- 
siderahle  voluntary  spasm  in  the  rii^/it 
hypochondrium  and  ri'^ht  iliac  fossa. 
Tlie  tem]ierature  record  is  shown 
in  the  accompanying  chart.  The 
leukocytes  numl)cred   g^oo  April  7th. 

Ai)ril  8th,  two  days  after  entrance,  the  tem])erature  rose  to  ic-\40 
F.  and  tlv  pain  increased.  A  surirical  consultant  saw  tlie  bo}'.  and 
Siiid  that  the  case  was  one  for  exj)loration  of  the  l>ile  ducts,  but  it  was 


?.--(;liarr  of 


2o6  DIFFERENTIAL   DIAGNOSIS 

decided  to  wait  until  the  boy's  parents  could  be  communicated  with. 
In  the  meantime,  dulness  and  diminished  breathing  were  found  in 
the  lo\\er  right  back,  and  on  April  loth  the  abdominal  rigidity  had 
almost  disappeared.  On  this  day  a  hypodermic  needle  was  intro- 
duced in  the  back  over  the  dull  area,  but  no  fluid  obtained.  An  .v-ray 
taken  April  13th  showed  no  lesion  of  the  lung  or  pleura  and  no  enlarge- 
ment of  the  cardiac  area  to  the  right.  So  far  the  diagnosis  was  wholly 
in  doubt. 

iVpril  15th,  nine  days  after  entrance,  a  double  pericardial  friction 
sound  was  heard  for  the  first  time,  and  the  right  border  of  cardiac 
dulness  on  the  le\el  of  the  fifth  rib  was  found  to  be  two  inches  from  the 
midsternal  line. 

Discussion. — Gall-stones  are  so  rare  in  boys  of  twelve  that  one 
should  be  very  slow  to  make  the  diagnosis,  no  matter  how  much  the 
symptoms  resemble  that  disease.  Pain  and  spasm  constitute  the 
whole  of  our  positive  e\"idence  pointing  toward  gall-stones,  though  the 
fever  shown  on  the  accomjjanying  chart  would  be  quite  consistent  with 
gall-bladder  inflammation.  Without  more  characteristic  colic,  with- 
out jaundice  or  palpable  gall-bladder,  we  should  not  make  the  diagnosis 
of  gall-stones  until  every  otlier  possibility  has  been  disproved. 

Abdominal  pain  in  children  always  points  toward  disease  of  the 
chest  (^pneumonia  or  ])leurisy)  as  well  as  of  the  abdomen.  In  the  well- 
meant  desire  to  solve  the  prol)lem  through  some  diagnosis  of  this  kind 
an  area  of  dulness  and  diminished  breathing  was  worked  out  in  the 
lower  right  l)ack,  a  most  dubious  region,  owing  to  the  varying  height 
of  the  liver  dulness.  Such  signs  as  were  found  were  not  substantiated 
in  any  ^^•ay  by  the  results  of  exploratory  ])uncture  and  v-ray  examina- 
tion. In  view  of  this  they  mayl)e  set  down  as  hallucinations  of  hearing, 
due  to  what  the  psychologists  call  "exj^ectant  attention.'' 

From  the  lips  of  the  majority  of  |)hysicians  we  should  surely  hear 
of  "rheumatism"'  or  "neuralgia''  as  explanations  of  an  obscure  pain 
like  this,  but  in  the  present  case  these  anticjuated  blanket-diagnoses 
may  be  excluded  without  qualification.  Boys  of  twelve  do  not  have 
neuralgia  or  rheumatism  at  the  sites  where  ])ain  is  comj)lained  of  here. 
We  must  demand  tliat  the  ])ain  shall  Ije  localized  at  or  near  a  joint 
before  the  word  "rheumatism''  can  find  any  place,  while  all  |)ain  called 
"neuralgic"  should  follow  the  known  anatomic  course  of  some  nerve. 

Inflammation  of  an  undescended  (subhejjatic)  appendix  is  suggested 
by  the  position  of  the  pain  and  S])asm.  The  onset  has  not  been  as 
sudden  nor  the  leukocyte  count  as  high  as  in  most  cases  of  a])])cndicitis 
associated  with  so  much  fe\"er  and  ]:)ain.     Nevertheless,  until  the  spasm 


RIGHT    HYPOCHONDRIAC    PAIN 


207 


disappeared  and  the  pericardial  friction  made  itself  apparent,  a  "high 
appendix"  could  not  be  ruled  out. 

We  may  ask  ourselves  whether  the  position  of  the  cardiac  impulse 
(fourth  interspace,  just  outside  the  nipple)  indicates  any  pathologic 
condition  or  has  any  bearing  upon  the  diagnosis.  The  answer  should 
be  in  both  cases,  no.  At  this  boy's  age  the  heart's  apex  is  not  infre- 
quently thus  situated. 

Until  the  appearance  of  the  pericardial  friction-rub  I  do  not  believe 
that  a  diagnosis  could  have  been  made  in  this  case,  nor  do  I  believe 
that  the  pericarditis,  which  ran  its  course  in  so  typical  a  wa}'  after  that 
date,  was  itself  the  cause  of  all  the  previous  symptoms.  Inhere  seems 
to  me  good  reason  to  believe  that  many  infections,  especially  in  young 
people,  are  in  their  early  stages  as  wide-spread  and  unlocalized  as  their 
symptoms.  It  is  probably  by  a  further  ste|)  in  the  progress  of  the  infec- 
tious process  that  inflammation  appears  in  a  well-marked  circum- 
scribed area  with  an  exudate  and  the  resulting  pathologic  changes. 
It  was  with  the  idea  of  producing  such  a  localization  of  a  pre\'iously 
general  ])roccss  that  French  T)hysicians  have  employed  subcutaneous 
injections  of  turpentine  to  bring  about  what  tliey  call  a  "fixation  alj- 
scess." 

Possibly  blood  cultures  would  have  helped  us  in  this  case.  They 
must  be,  for  the  present,  our  only  means  of  recognizing  man}'  infections 
in  their  early,  unlocalized  stage. 

Outcome. — On  the  nineteenth  the  area  of  cardiac  dulness  had  con- 
sideraljl}-  increased  in  size,  and  now  extended  well  out  into  the  left  axilla. 
I'he  leukocyte  count  had  meantime  risen  from  Q2Co  at  entrance  to 
i9,Qco  on  the  eighteenth.  The  friction  sound  had  meantime  disap- 
peared, while  dulness  and  diminished  breath-sounds  were  detected  in 
the  left  lower  back. 

On  the  twentieth  dulness  in  the  left  axilla  was  found  to  extend 
nearly  to  tlic  ])osterior  axillary  line.  The  leukocytes  numl)ered  22.000, 
witli  80  ])er  cent,  of  polynuclear  cells.  The  diagnosis  of  pericardial 
elfusion  was  then  made,  and  a  trocar  was  inserted  in  the  fifth  space,  one 
inch  outside  the  left  nip])]e.  and  just  bevond  the  ])al])able  cardiac  impulse. 
Seven  ounces  of  turbid,  blood-tinged  lluid  were  ()l)tained,  with  a  s]»ecilic 
gra\'it\'  of  1022;  2.T  per  cent.  all)umin.  The  sediment  of  tliis  ll'.u'd 
showcfl  S7.5  per  cent,  of  |)oh-nuclear  ci-lls.  Xo  tuljcrcle  bacilli  ■'.ere 
found.  Immediatel}'  after  the  ta])ping  a  doul)le  friction-sor.nd  co'iid 
again  Ix;  heard  all  o\-er  t!ie  precordia,  and  LTcat  pain  was  roiniilaincd 
of  in  this  region.  P;.in  and  audible  friction  continued,  with  sonu-  iutiT- 
vals  of  relief,  durim'  the  nt'xt  three  davs. 


2o8  DIFFERENTIAL  DIAGNOSIS 

April  23d  the  case  was  again  seen  by  a  surgical  consultant,  and  on 
the  twenty-fourth  the  pericardium  was  opened  and  drained  by  resecting 
a  costal  cartilage.  The  boy  afterward  developed  a  left  pleural  effusion, 
which  finally  became  purulent,  but  after  rather  a  tedious  illness  he 
completely  recovered. 

N^otes  of  Treatment. — The  bowels  were  moved  by  calomel,  \  grain 
every  fifteen  minutes  until  ten  doses  were  given;  afterward  by  cascara 
and  by  an  enema.  For  the  pain,  hot  fomentations  and  turpentine 
stupes  were  given.  A  mustard  poultice  to  the  abdomen  also  gave  some 
relief,  and  later  an  ice-bag  was  placed  over  the  heart  and  about  |  grain 
of  morphin  was  given  daily  by  subcutaneous  injection. 

Diagnosis. — Pericardial  effusion. 

Case  97 

A  highly  neurotic  Jewish  boy  of  eighteen  was  seen  June  19,  1907. 
His  illness  began  in  No\'ember,  1906,  when  for  two  weeks  he  \N'as  troubled 
by  pain  in  the  right  loin  and  right  back,  together  with  "dizzy  headaches" 
and  weakness  in  his  legs.  He  believes  that  he  strained  himself  in  lifting 
a  heavy  packing-case  in  October,  1906.  In  the  latter  part  of  December 
he  had  a  similar  but  milder  attack.  He  states  that  since  January  20th 
he  has  suft'ered  from  constant  pain  in  the  right  loin,  frequently  catching 
him  with  a  severe  stitch  on  inspiration.  Occasionally  the  pain  has 
shot  down  from  his  side  toward  the  groin  or  up  toward  the  epigastrium. 
His  urine  is  usually  clear,  but  sometimes  stained  red,  and  full  of  floating 
particles.     He  has  gained  in  weight,  but  lost  in  strength  since  February. 

In  January  he  was  carefully  examined,  but  no  disease  found.  On 
June  12th  his  urine  showed  a  slight  trace  of  albumin,  with  many 
leukocytes  and  blood-cells  in  the  sediment.  On  June  19th  a  physical 
examination  was  negative  except  that  the  right  rectus  abdominalis  was 
spastic,  and  there  was  tenderness  over  the  right  side,  most  marked  at 
the  edge  of  the  ribs,  in  the  right  nipple-line,  and  in  the  right  iliac 
fossa. 

At  the  time  of  this  examination  the  lower  edge  of  the  right  kidnc}' 
was  palpable  on  deep  inspiration,  and  there  was  a  slight  tenderness 
along  the  lower  dorsal  and  lumbar  spine.  The  movements  of  the  spine 
were  free.  He  had  no  fever  and  no  increase  in  the  leukoc}"tes.  The 
urine  varied  greatly  in  gravity,  being  twice  below  1008  and  three  times 
above  1020  within  twenty-four  hours.  It  always  contained  a  very  slight 
trace  of  albumin,  and  in  the  sediment  a  very  small  number  of  blood- 
cells  and  leukocytes.  One  ST)ecimen  showed  a  blood-clot  the  size  of  a 
bean. 


RIGHT   HYPOCHONDRIAC    PAIN  209 

Cystoscopy  was  done  on  the  twenty-sixth,  and  showed  on  the  floor 
of  the  bladder  "a  brownish,  cyhndric,  putty-hke  plug."  The  orifice 
of  the  right  ureter  was  greatly  dilated,  and  a  little  pus  was  seen  to  issue 
from  it.     A  strong,  clear  stream  of  urine  issued  from  the  left  ureter. 

Discussion. — In  the  actual  presence  of  this  patient  it  was  far  more 
difficult  than  in  reading  the  printed  case  to  avoid  being  unduly  impressed 
by  his  neurotic  temperament.  Any  one  so  manifestly  and  annoyingly 
self-centered,  especially  if  he  be  of  the  Jewish  race,  runs  a  considerable 
risk  of  being  falsely  accused  or  falsely  suspected  of  being  "merely  a 
neurotic."  Our  better  judgment,  however,  should  make  it  clear  that 
there  is  something  else  in  the  background. 

The  patient  himself  was  inclined  to  attribute  all  his  symptoms  to 
the  strain  suffered  in  the  previous  October,  but  on  careful  questioning 
it  was  clear  that  the  symptoms  did  not  make  their  appearance  until 
some  weeks  after  the  date  of  the  supposed  strain. 

We  may  note  that  in  the  physical  examination  there  are  no  data 
regarding  the  condition  of  the  sacro-iliac  joints.  Many  of  the  symptoms 
here  described  could  be  accounted  for  by  some  of  the  acute  lesions  of 
those  joints.  In  fact,  however,  the  joints  were  normal,  although  this  is 
not  stated  in  the  text. 

The  chief  moral  of  this  case  is  the  impossibility  of  a  satisfactory 
diagnosis  through  the  ordinary  methods  of  ])hysical  examination  in 
many  cases  involving  the  right  upper  abdominal  quadrant.  Without 
cystoscopy  a  "  high  appendix  "  (sec  case  96)  could  not  have  been  excluded, 
and  the  diagnosis  must  have  remained  long  in  doubt;  indeed,  the  case 
is  introduced  largely  to  illustrate  the  importance  of  cystoscopy  in  cases 
involving  neither  bladder  symptoms  nor  ordinary  "renal  colic." 

It  remains  merely  to  discuss  what  lesion  we  should  e.xpcct  to  find 
in  the  kidney  on  the  basis  of  the  facts  here  given.  Malignant  disease 
of  the  kidney  is  rare  at  eighteen,  and  cannot  be  recognized  in  the  al)sence 
of  tumor  and  hematuria.  Tuberculosis  of  the  kidney  should  ]:)roduce 
fever,  pyuria,  and  \"esical  discomfort.  In  the  majority  of  cases  also  a 
tumor  would  be  ])alj)able  after  eight  months  of  sutTering.  Renal  stone 
seems  the  most  reasonable  diagnosis. 

Outcome. — An  .v-ray  ])hite  taken  on  the  twenty-eighth  sliowcd  a 
shadow  apparentlv  in  the  ])el\is  of  the  riglit  kidney.  ( )n  the  same  da}' 
operation  confirmed  the  findings  of  the  .v-ray,  though  the  stone  crumbled 
uj)  into  fine  sand  wlien  touched.     The  patient  made  a  good  rec(nei\'. 

Diagnosis. — Renal  stone. 
ij 


2IO  DIFFERENTIAL  DIAGNOSIS 

Case  98 

A  factory-hand  of  twenty-six,  whose  family  history  was  unimportant, 
had  typhoid  fever  when  he  was  eight  years  of  age,  and  has  suffered  from 
constipation  for  the  past  ten  years.  With  the  exception  of  20  cigarettes 
a  day,  his  habits  are  good. 

For  the  past  four  months  he  has  been  more  constipated  than  usual, 
his  bowels  moving  only  once  in  four  or  five  days.  For  the  past  two  weeks 
he  has  been  troubled  by  headache,  which,  however,  has  disappeared 
to-day.     During  this  time  his  appetite  has  been  poor. 

Eight  days  ago  he  began  to  have  a  steady,  moderately  severe  pain 
at  the  right  costal  margin.  Five  days  ago  he  noticed  that  his  eyes 
were  yellow,  and  that  his  urine  w^as  of  a  deep-red  color. 

On  physical  examination  his  sclera  was  found  to  be  moderately 
yellow,  and  his  skin  considerably  discolored.  Both  tonsils  were  slightly 
enlarged,  and  there  were  a  few  white  spots  upon  the  right  tonsil.  The 
heart's  impulse  was  not  seen  or  felt.  The  sounds  were  best  heard  in 
the  fourth  interspace,  three  inches  from  the  median  line.  There  were 
no  murmurs  nor  other  modifications  of  the  sounds.  There  was  rigidity 
in  the  right  upper  quadrant,  with  tenderness  and  dulness  extending 
an  inch  and  a  half  below  the  ribs.  A  sharp  edge  could  be  felt  to  descend 
on  full  inspiration  at  this  point.  The  upper  border  of  liver  dulness  was 
at  the  sixth  rib.  The  abdomen  was  otherwise  negative,  as  were  the 
other  organs.  The  urine  contained  bile  and  a  very  slight  trace  of 
albumin,  but  was  otherwise  normal.  There  was  no  anemia  and  no 
leukocytosis. 

The  patient  was  first  seen  on  the  twenty-second  of  February.  Under 
sodium  phosphate,  20  grains  after  meals,  and  a  hot-water  bag  to  the 
hypochondrium,  he  1)ecame  comfortable,  and  by  [March  4th  his  yellow 
color  had  considerably  faded.  His  constipation  was  later  treated  by 
cascara  and  by  enemata. 

Discussion. — Any  case  involving  jaundice  and  a  past  history  of 
typhoid  fever  suggests  a  typhoid  cholecystitis  with  the  resulting  gall- 
stones, and  this  possibility  cannot  be  excluded  here.  Without  colic, 
fever,  chills,  or  vomiting,  and  without  a  palpable  gall-bladder,  we 
cannot  get  l^eyond  suspicions  in  this  direction. 

Cases  of  relatively  short  jaundice,  with  or  without  slight  enlargement 
of  the  li\er,  such  as  is  here  present,  are  traditionally  labeled  as  "catarrhal 
jaundice''  if  nothing  more  definite  appears  in  sight;  but  it  is  always 
quite  possible  that  we  may  be  dealing  in  these  cases  either  with  a  transient 
obstruction  due  to  stone  or  to  an  infectious  cholangitis  travelinfr  down 


RIGHT   HYPOCHONDRIAC    PAIN  211 

the  ducts  rather  than  up.  There  is  Httle  if  any  proof  that  so-called 
catarrhal  jaundice  spreads  upward  from  an  inflamed  duodenum.  For 
the  present,  however,  and  until  our  knowledge  of  the  subject  is  con- 
siderably increased,  we  must  be  content  with  the  old  term. 

Outcome. — On  the  fifteenth  of  March  his  color  was  practically 
normal  and  the  bile  was  gone  from  his  urine.  He  felt  perfectly  well 
and  was  discharged.     There  has  been  no  recurrence  in  three  years. 

Diagnosis. — Catarrhal  jaundice. 

Case  99 

A  widower  of  seventy-seven  entered  the  hospital  February  25,  1908. 
He  has  always  followed  the  trade  of  carpenter  and  has  been  strong 
and  well  except  for  two  attacks  of  malaria,  one  during  the  Civil  War 
(when  he  served  for  three  years),  and  the  other  eight  years  ago. 

Seventeen  years  ago  he  \\as  kept  out  of  work  for  fourteen  months 
on  account  of  symptoms  supposed  by  one  doctor  to  be  due  to  cancer 
of  the  stomach,  by  other  doctors  to  be  caused  by  liver  trouble.  At  that 
time  he  suffered  pain  under  the  right  costal  margin;  this  pain  shot 
through  into  his  back  and  was  associated  with  vomiting  and  frequent 
black  stools.  He  never  ^■omitcd  blood,  was  never  jaundiced,  and  had 
no  chills,  fever,  or  colic.  The  pain  was  always  worse  at  night,  but  had 
no  relation  to  the  character  of  food  nor  to  the  time  of  taking  it. 

He  completely  recovered  from  this  attack,  and  has  been  at  \\ork 
ever  since  except  for  a  period  of  two  montlis,  seven  years  ago,  when 
he  was  in  the  Massachusetts  General  Hos[)ital  for  an  attack  diagnosed 
as  duodenal  ulcer.  At  that  time  he  frc({ucntly  ])as?cd  blood  in  his 
stools  and  his  weight  fell  to  200  ])ounds,  where  it  has  since  remained. 

One  year  later  he  had  an  attack  of  vomiting  with  tarry  stools,  similar 
to  those  ])asscd  the  year  before,  1)ut  was  well  again  in  a  few  days.  TJnre 
years  ago  he  had  an  attack  of  vomiting  lasting  nine  hours;  there  was 
no  blood  in  his  stools  at  that  time,  but  he  had  to  remain  in  the  house  for 
two  weeks.  Between  the  attacks,  /.  r.,  fc^r  most  of  the  last  fifteen  years. 
he  has  called  liimsclf  i^cll.  Ticenly  monlJis  ago  lie  had  a  se\"ere  attack 
of  pain  under  the  riglit  costal  margin,  accompanied  this  time  In-  tlx- 
appearance  of  a  red  S])ot  on  the  skin  just  l)elow  the  ribs.  He  was  told 
by  his  doctor  that  he  ])rol)al>ly  IkuI  an  abscess  of  llie  li\'er.  After  a 
(lay  or  two  of  tliis  ])ain  liis  lu'ine  suddenly  became  ]iink  and  rtiTi;.ine(i 
so  for  \vn  (la}'s;  tlie  jiain  and  the  red  spot  then  gradua.IIy  M;iisi(k(i, 
and  the  urine  l)ecame  normal  in  a])pearance. 

.-1  year  ago  he  had  an  attack  of  indigestion,  ^\•itl^  pain  undir  tlie  right 


212  DIFFERENTIAL  DIAGNOSIS 

costal  margin  and  fainted,  so  that  he  fell  out  of  his  chair  while  the 
doctor  was  talking  to  him.     His  habits  have  always  been  excellent. 

For  tlie  past  six  months  he  has  had  a  continuous,  dull  pain  under  the 
right  rib-margin.  This  pain  gets  worse  on  moving  about,  is  not  affected 
by  food,  and  occasionally  becomes  severe,  radiating  to  other  points  of 
the  abdomen  and  to  the  back.  He  had  such  an  attack  three  nights 
ago,  but  was  relieved  by  drinking  three  glasses  of  cold  water. 

Six  weeks  ago  he  noticed  under  the  right  costal  margin  a  swelling, 
which  has  steadily  increased  in  size  and  become  exceedingly  tender 
to  the  touch.  He  has  had  no  fever,  no  jaundice,  no  vomiting,  and  no 
change  in  the  amount  or  color  of  his  urine.  He  has  noticed  nothing 
remarkable  about  his  stools. 

Physical  examination  reveals  no  emaciation  and  nothing  abnormal 
in  the  chest.  The  right  costal  margin  is  markedly  prominent,  and  in 
the  center  of  this  prominence  is  a  rounded  protrusion  which  is  very 
tender.  (See  Fig.  33.)  The  tender  mass  is  firm  and  somewhat  movable, 
sometimes  reaching  the  median  line  in  the  epigastrium.  The  edge  of  the 
liver  is  felt  just  below  the  mass,  and  is  apparently  somewhat  irregular. 

Physical  examination  is  otherwise  negative,  likewise  the  blood  and 
urine.  His  stools  contain  no  occult  blood.  After  further  observation 
it  was  found  that  the  tumor  would  move  with  a  change  in  the  patient's 
position  until  it  reached  the  left  costal  margin;  with  this  motion  the 
upper  border  of  liver  dulness  also  moved  downward.  Examined  by 
means  of  a  stomach-tube,  the  stomach  was  found  to  reach  one  inch 
below  the  navel  when  inflated.  The  upper  border  was  at  the  tip  of 
the  ensiform  cartilage.  The  stomach-contents  after  a  test-meal  showed 
hydrochloric  acid,  o.ii  per  cent.,  and  total  acidity,  0.17;  no  occult 
blood. 

Discussion. — The  early  history  of  this  case  points  straight  to  the 
diagnosis  of  duodenal  ulcer.  Between  these  initial  symptoms,  how- 
ever, and  the  sufferings  of  the  last  six  months,  there  are  two  curious 
episodes  which  may  be  first  briefly  discussed. 

How  are  we  to  explain  the  appearance  of  the  red  spot  in  the  right 
hypochondrium  and  the  close  sequence  of  pink-colored  urine?  Since 
these  symptoms  began  together  and  ceased  together,  it  is  reasonable 
to  look  for  a  common  cause.  We  may  conjecture  that  the  spot  on 
the  h}-pochondrium  was  due  to  a  "purpuric"  extravasation  of  blood, 
and  that  the  urinary  oloration  was  due  to  a  similar  ecchymosis  in  the 
kidney.  Such  occurrences  would  be  easily  explicable  were  jaundice 
present,  for  we  are  ^^■eIl  accustomed  to  see  all  sorts  of  oozing  and  hemor- 
rhages in  jaundiced  patients.     It  has  been  pointed  out,  however,  by  Dr. 


f'ig-  33- — "I>iagrain  of  signs  recorded  in  a  patient  who  complains  of  i)ain  and  swelling 

under  the  ri^ht  ribs. 


RIGHT   HYPOCHONDRIAC   PAIN 


213 


Maurice  H.  Richardson  and  others,  that  the  hemorrhagic  tendency  in 
diseases  of  the  Uver  is  not  confined  to  those  which  produce  jaundice. 
If,  therefore,  we  assume,  as  seems  warranted  by  the  outcome  of  the 
case,  that  this  patient  may  have  had  Hver  disease  at  the  time  of  the 
phenomena  we  are  now  attempting  to  explain,  the  idea  of  multiple 
hemorrhage  would  be  plausible. 

What  shall  we  say  of  the  fainting  attack  which  occurred  a  year  ago? 
Since  this  patient  has  had  repeated  and  profuse  intestinal  hemorrhages, 
presumably  from  duodenal  ulcer,  it  seems  not  unlikely  that  the  faintness 
was  due  to  the  repetition  of  such  a  hemorrhage. 

Coming  now  to  the  events  of  the  last  six  months,  we  find  them 
characterized  by  continuous  pain  in  the  region  of  the  liver,  apparently 
unconnected  with  the  taking  of  food,  but  complicated  later  by  enlarge- 
ment and  irregularity  of  the  liver. 

In  patients  who  have  never  lived  under  conditions  favorable  to 
hydatid  infection  (association  with  sheep  and  sheep-dogs,  especially 
in  Greece,  Australia,  and  Iceland),  we  need  consider  only  two  diseases 
to  explain  a  nodular  enlargement  of  the  liver,  viz.,  cancer  and  syphilis. 
The  nodules  due  to  cirrhosis  are  rarely  if  ever  palpable  through  the 
aljdominal  walls.  The  hepatic  enlargements  due  to  passive  congestion, 
fatty  infiltration,  leukemia,  pseudoleukemia,  amyloid  disease,  obstruc- 
tive jaundice,  and  abscess  do  not  produce  a  nodular  surface.  Our 
problem,  then,  is  reduced  to  narrow  limits — cancer  or  syphilis.  I 
have  never  known  syphilis  to  produce  so  much  pain  as  was  suffered 
in  this  case.  The  absence  of  fever  is  also  against  this  diagnosis.  The 
same  is  true  in  a  lesser  degree  of  the  absence  of  syphilitic  history  and 
syj)hilitic  lesions  in  other  parts  of  the  body. 

Cancer  of  the  liver — which  seems  the  most  prolxible  ex]')lanati(m 
of  this  man's  present  sulTerings — is  rarely  primary.  We  may  suppose 
it  to  be  secondary  to  a  growth  implanted  in  tlie  site  of  the  peptic  ulcer 
whicli  we  have  good  reason  to  l^clicve  existed  some  years  ago.  Yet 
we  have  no  definite  evidence  of  any  sucli  growth  in  the  stomacli  or 
duodenum,  and  the  Suirting-])oint  of  tlie  disease  must  be  left  in  uncer- 
tainty. 

Outcome. — On  the  seventh  of  Afarcli  tlic  abdonu-n  was  opened 
and  sliowed  a  firm,  nodular  mass  of  malignant  disease  in  the  Hver  about 
the  size  of  a  cocoanut.  The  abdomen  was  closed  and  the  ]xilient  Kll 
tlic  lios])ital  on  the  nineteenth  of  March.     He  died  three  months  later. 

Diagnosis. — 1  Iej)atic  cancer. 


214  DIFFERENTIAL    DIAGNOSIS 

Case  100 

The  patient  is  a  stable-man  of  thirty-six  who  was  first  seen  March 
7,  1908.  He  had  a  good  deal  of  trouble  with  his  stomach  three  years 
ago,  but  since  then  has  been  well  until  four  weeks  ago,  when  he  began 
to  vomit  and  to  have  severe  pain  in  the  right  upper  quadrant.  His 
vomitus  sometimes  contains  large  quantities  of  food.  The  pain  is  very 
severe,  and  for  the  last  two  weeks  has  forced  him  to  walk  the  floor  every 
night  and  to  take  morphin  tablets. 

At  present  his  pain  is  at  its  worst  about  two  hours  after  meals;  it  is 
also  very  troublesome  at  night;  sometimes  it  shoots  across  to  the  left 
costal  margin  and  up  to  the  right  nipple.  For  three  weeks  he  has  eaten 
only  bread,  milk,  and  tea. 

On  physical  examination  his  right  pupil  was  found  to  be  slighdy  larger 
than  his  left.  Both  react  normally.  The  skin  was  everywhere  notably 
smooth  and  satin-like  to  the  touch.  His  radial  arteries  were  considerably 
thickened,  and  his  aortic  second  sound  was  greater  than  his  pulmonic; 
otherwise  nothing  wrong  was  found  in  the  chest.  There  was  moderate 
tenderness  in  the  right  upper  quadrant.  Physical  examination,  includ- 
ing the  blood  and  urine,  was  otherwise  normal.  A  stomach-tube  passed 
before  breakfast  showed  no  fasting  contents.  The  capacity  of  the 
stomach  was  24  ounces,  and  the  percussion  outlines  after  distention 
with  air  indicated  no  dilatation  of  the  organ.  Microscopic  and  chemical 
tests  of  the  gastric  contents  after  a  test-meal  revealed  nothing  abnormal. 

It  was  later  ascertained  that  this  attack  followed  a  debauch  in  which 
he  took  whisky,  beer,  and  ale  to  excess  for  a  week,  "which,"  he  says, 
"scalded  his  insides."     Before  that  he  had  taken  no  liquor  for  years. 

Discussion. — By  force  of  ancient  tradition  we  are  accustomed 
to  think  of  syphilis  as  a  cause  for  all  pains  which  are  worse  at  night. 
We  have  seen,  however,  from  the  cases  already  studied  in  this  book, 
that  pain  due  to  hyperchlorhydria,  to  peptic  ulcer,  gall-stones,  and 
lead-i)oisoning,  is  also  aggravated  at  night  in  many  cases.  In  the  pres- 
ent case  the  suspicion  of  syphilis  is  somewhat  increased  by  the  finding 
of  thickened  radial  arteries,  accentuated  aortic  second  sound,  and 
unequal  pupils;  yet  there  is  nothing  sufficiently  definite  in  the  physical 
examination  to  justify  a  diagnosis  of  visceral  sy})hilis. 

Of  the  other  causes  of  pain  above  mentioned  there  is  not  sufficient 
evidence,  though  only  lead  can  be  positively  excluded.  The  most 
significant  point  of  the  |)hysical  examination  is  the  satin-like  surface  of 
the  skin.  This  quality,  when  well  marked  in  workingmen,  is  strong 
evidence  of  recent  alcoholism,  and  when,  as  in   this  case,  the  history 


RIGHT   HYPOCHONDRIAC    PAIN  21 5 

does  not  at  once  suggest  any  such  habit,  the  evidence  obtained  through 
a  routine  physical  examination,  which  includes  a  note  on  the  condition 
of  the  skin,  may  be  most  important.  This  is  especially  true  when  no 
other  cause  can  be  found  for  the  sudden  appearance  of  marked  gastric 
disturbances  in  an  adult. 

Outcome. — The  patient  was  put  on  Lenhartz's  diet,  and  in  a  cou])le 
of  weeks  seemed  perfectly  well. 

Diagnosis. — Alcoholic  gastritis. 

Case  101 

A  young  Jewish  house  painter  eighteen  years  old,  who  was  first  seen 
March  i6,  1908,  has  had  several  attacks  of  rheumatism,  but  neverthe- 
less has  considered  himself  well  until  five  weeks  ago,  when  he  began 
to  suffer  from  pain  in  the  right  upper  quadrant,  together  with  dyspnea 
on  exertion,  weakness,  and  cough,  with  frothy  white  sputa.  For  the  past 
ten  days  he  has  been  in  lK^d,  and  found  it  impossible  to  lie  down  at  night 
on  account  of  cardiac  distress. 

On  physical  examination  he  was  found  to  be  pale  and  slightly  cyanotic. 
The  veins  of  his  neck  were  markedly  distended  and  showed  a  systolic 
pulsation.  The  carotids  also  pulsated  vigorously.  The  heart  showed 
a  diffuse  pulsation  in  the  second,  third,  fourth,  and  fifth  left  interspaces, 
but  the  maximum  impulse  was  seen  and  felt  in  the  sixth  spac3  i^  inches 
outside  of  the  nipple-line.  The  area  of  cardiac  dulness  extended  2\ 
inches  to  the  right  of  midsternum,  and  the  cardiac  impulse  could  be 
felt  for  nearly  an  inch  Ijcyond  the  right  of  midsternum.  The  heart 
was  regular;  rate,  no.  At  the  apex  a  systolic  and  a  ])resyslolic  murmur 
were  heard.  In  the  left  axilla  and  along  the  left  sternal  border  the  sys- 
tolic murmur  was  much  more  intense,  and  a  musical  diastolic  murmur 
was  heard.  The  juilmonic  second  sound  was  mucii  accentuated;  the 
aortic  second  sound  was  a1)sent.  The  ])ulse  was  of  low  tension  and 
of  the  Corrigan  ty])e,  but  no  capillary  pulse  was  demonstrated.  The 
lungs  were  normal  except  for  the  presence  of  a  few  moist  rales  at  the 
base  of  the  left  axilla.  There  was  dulness  in  the  flanks,  shifting  whh 
change  of  {)osilion.  The  edge  of  the  li\'er  was  felt  three  inches  below  the 
ribs.  Tile  organ  was  tender,  anrl  moved  with  each  systole.  The  urine 
a\eraged  30  ounces  in  twenty-four  hours,  with  a  specific  gnnily  ot  icj;. 
There  was  a  sHght  trace  of  all)un"iin  and  a  few  granular  casts.  The 
blood  showed  nothing  abnormal.     There  was  nc^  fe\XT. 

Discussion. — In  relation  to  tlie  prognosis  and  Irealment  ot  this 
case  it  is  important  to  form  some  estimatt,'  of  its  (huMtion.  f.wn  a 
cursorv  studv  of   the  cardiac   lesion   luust  con\ince   us   that   the   heart 


2l6  DIFFERENTIAL   DIAGNOSIS 

was  diseased  for  some  time  previous  to  the  last  five  weeks,  during  which 
he  has  called  himself  sick.  In  view  of  the  size  of  the  heart  and  the 
character  of  the  murmurs  (which  suggest  stenoses  and  therefore  chronic- 
ity)  we  may  assume  that  the  disease  has  existed  for  months,  if  not  for 
years. 

Cardiac  lesions  involving  marked  hypertrophy  are  most  often  due  to: 

(a)  Valvular  disease. 

(b)  Chronic  nephritis. 

(c)  Adherent  pericardium,  with  or  without  interstitial  myocarditis. 
Renal  disease  may  be  ruled  out  by  the  low  tension  of  the  pulse  and 

by  the  characteristics  of  the  urine.  Adherent  pericardium  by  itself 
cannot  produce  so  marked  a  diastolic  murmur  and  would  not  account 
for  the  arterial  changes  (Corrigan  pulse).  We  cannot  exclude  the 
possibility  of  adherent  pericardium  complicating  other  lesions,  but 
alone  it  would  not  account  for  the  facts. 

The  signs  certainly  point  to  the  existence  of  disease  at  the  aortic 
valve,  and  probably  to  a  similar  condition  at  the  mitral.  Is  the  aortic 
lesion  single  or  double?  The  physical  signs  give  us  assurance  only  of 
aortic  incompetence,  but  postmortem  experience  has  led  me  to  believe 
that  whenever  aortic  regurgitation  is  recognized  in  a  cardiac  case  of 
considerable  duration  occurring  in  a  young  person,  aortic  stenosis  is 
almost  always  present  as  well,  whether  the  physical  signs  indicate  it  or 
not.  In  other  words,  aortic  disease  due  to  endocarditis  almost  always 
produces  stenosis  as  well  as  regurgitation  if  it  has  lasted  longer  than  a 
few  weeks. 

As  this  case  occurred  previous  to  the  discovery  of  the  Wassermann 
reaction,  we  had  no  means  of  ascertaining  whether  the  aortic  lesions 
were  possible  or  probably  due  to  syphilis. 

As  regards  the  mitral  ^■alve,  we  have  no  way  of  being  sure  whether 
or  not  an  endocarditis  has  been  at  work  there.  The  systolic  murmur 
might  be  due  to  relative  insufficiency  without  lesion  of  the  valve  itself, 
while  the  presystolic  murmur  might  be  of  the  type  described  ])y  Austin 
Flint.  But  the  strong  accentuation  of  the  pulmonic  second  sound 
gives  us  reason  slightly  to  favor  a  definite  mitral  lesion. 

Obviously,  there  is  ])assive  congestion  of  the  liver,  explaining  the 
pain  and  tenderness  in  the  right  liypochondrium,  and  these  facts, 
together  with  tlie  gathering  ascites  (shifting  dulncss  in  the  flank),  make 
it  clear  that  the  tricuspid  A-alve  is  leaking  badly.  This  still  further 
inclines  us  to  assume  an  organic  mitral  disease.  The  urine  is  typical 
of  passive  renal  congestion. 

Whv  should  the  heart  have  begim  to  fail  iust  at  this  time?     We  are 


RIGHT   HYPOCHONDRIAC    PAIN  21 7 

apt  to  explain  such  events  through  a  so-called  break  of  compensation 
supposedly  of  mechanical  origin.  The  individual  is  supposed  to  have 
reached  and  overpassed  the  limits  of  his  cardiac  reserve  power.  It 
has  been  pointed  out,  however,  especially  by  Dr.  Charles  Hunter  Dunn,* 
that  many  of  the  so-called  breaks  of  compensation,  occurring  as  they 
usually  do  without  any  known  strain  or  overexertion,  are,  in  fact,  due  to 
a  fresh  outbreak  of  the  endocarditis  which  has  previously  been  smoulder- 
ing upon  the  diseased  valve.  This  possibility  is  especially  to  be  thought 
of  when  the  supposed  break  of  compensation  comes,  as  it  were,  out 
of  a  clear  sky,  and  is  accompanied  by  a  polynuclear  leukocytosis,  with 
or  without  a  slight  elevation  of  temperature. 

Outcome. — The  boy  lived  in  the  hospital  from  March  6th  to  April 
8th.  At  no  time  did  he  show  any  improvement;  and  despite  digitalis, 
strychnin,  morphin,  magnesium  sulphate,  diuretin,  calomel,  squills, 
and  other  drugs,  he  died  on  April  8th. 

Autopsy  showed  fibrous  endocarditis  of  the  mitral  and  aortic 
valves,  with  stenosis  and  insufficiency  of  both.  There  was  also  a  fresher 
verrucose  process  on  both  valves,  and  some  acute  degeneration  of  the 
myocardium. 

Diagnosis. — See  last  paragraph. 

Case  102 

An  Irish  lal^orer  fifty-eight  years  old  entered  the  hospital  February 
18,  1908.  His  family  history  was  unimportant,  but  he  stated  tliat  for 
the  past  two  years  he  had  had  ''bronchitis,"  and  that  he  had  used  each 
week  70  cents'  worth  of  tobacco  all  his  life,  until  eighteen  months  ago; 
very  little  since.  Since  the  middle  of  October  his  "bronchitis"  has  been 
very  se\"ere,  and  he  has  felt  weak  and  tired,  but  as  the  rest  of  tlic  family 
were  out  on  a  strike,  he  had  to  keci)  at  work.  Three  days  ago  he  got 
wet  through,  and  since  then  he  has  been  in  ])cd.  He  com])lains  of 
j)ain  in  the  right  hypochondrium,  with  dys])nea  and  cough,  es])ecial]}' 
\\hen  he  is  ^vorkin^.  He  niiscs  yellow  s])Utum  in  cor.sidcrablc  airoiints, 
but  has  ne\"er  raised  blood.  Tast  Xo\ember  he  was  troubled  for  some 
weeks  with  ])ain  in  the  left  side  of  his  chest.  Two  years  ago  he  weighed 
185  pounds;  now  he  wc-ighs  1^5.  W'henewr  he  coughs  he  Ikis  an 
aggraxation  of  the  pain  in  the  rii^'ht  side  of  the  alxlomen  lieneath  th.e 
ribs. 

T'ln'sical  examination  showed  small,  irregular  pupils,  wl.ieh  reacted 
normalh'.  The  throat  was  reddened  and  sli^litl}'  s'vollen;  {\:v  ]u'art".s 
action  irregular  in  force  an.d  rlnllim,  but  shoninu:  no  oilier  abnormality. 

Miunii,  Imir.  Ami  r.  Mcil.  Ass'C,  1  iliru.irv  (j,   1007. 


2i8  DIFFERENTIAL  DIAGNOSIS 

His  pulses  were  apparently  of  increased  tension,  and  his  arteries  easily 
palpable,  but  on  measurement  his  blood-pressure  showed  only  120 
mm.  Hg.  There  was  no  dyspnea  in  the  recumbent  position  and  no 
edema  anywhere.  The  lower  two-thirds  of  the  right  lung  behind 
showed  dulness.  At  the  base  there  was  intense  bronchial  breathing, 
with  marked  increase  of  voice-sounds  and  fremitus  and  many  fine, 
moist  rales.  These  sounds  became  less  marked  in  the  upper  portion 
of  the  dull  area. 

During  a  ten  days'  stay  in  the  hospital  there  was  no  notable  change 
in  the  physical  signs.  The  patient  had  an  irregular  pyrexia,  reaching 
as  high  as  102°  F.  at  frequent  intervals,  but  always  falling  below  normal 
at  some  time  in  the  twenty-four  hours. 

Discussion. — Chronic  bronchitis  (usually  with  disseminated  bron- 
chiectatic  ca^•ities)  is  the  commonest  cause  of  a  long-standing  winter 
cough  in  elderly  people.  The  fact  that  this  patient's  cough  appears 
to  last  all  the  year  round  does  not  exclude  this  type  of  bronchiectasis, 
but  the  fact  that  it  is  accompanied  by  loss  of  weight,  by  pain  in  the 
right  hypochondrium,  and  by  intense  bronchial  respiration  at  the  base 
does  not  fit  in  well  with  bronchitis  and  bronchiectasis.  The  sputum 
examination  is  very  important  in  solving  this  problem. 

The  irregularit}^  of  the  heart  and  the  evidence  of  degeneration  in 
the  peripheral  arteries  make  us  wonder  whether  the  signs  at  the  base 
of  the  right  lung  may  not  represent  a  hydrothorax  due  to  cardiac  weak- 
ness.  The  signs,  to  be  sure,  are  by  no  means  typical  of  hydrothorax, 
but  might  possibly  be  consistent  with  that  condition,  were  it  not  that 
the  absence  of  dyspnea  and  edema  points  strongly  against  the  existence 
of  any  cardiac  weakness  sufficient  to  account  for  hydrothorax. 

If  we  fix  our  attention  upon  the  physical  signs  alone,  there  is  much 
to  suggest  a  pulmonary  abscess,  dependent  either  upon  a  postpneumonic 
empyema  rupturing  into  a  bronchus  or  upon  some  unknown  cause 
("  primary  pulmonary  abscess  ") .  But  the  long  duration  of  the  sym]:)toms 
and  the  lack  of  any  suggestion  of  acute  onset  make  this  rather  unlikely. 

But  for  the  unusual  position  of  the  signs,  it  would  be  natural  to 
consider  pulmonary  tuberculosis  first  of  all  in  this  case.  Even  as  it  is 
this  disease  is  by  no  means  to  be  excluded.  Repeated  and  thorough 
examinations  of  the  sjxita  are  called  for. 

Outcome. — The  sputum  showed  many  tubercle  bacilH  and  also 
many  pneumococci,  Ijoth  within  and  outside  of  the  leukocytes.  The 
patient  remained  in  the  hospital  until  the  second  of  March  without  show- 
ing any  considerable  change  in  any  res|)ect,  cxccjit  that  he  gained  4 
pounds  in  weight.     He  is  troubled  greatly  with  insomnia,  for  which 


RIGHT   HYPOCHONDRIAC    PAIN  219 

he  was  given  chloral  hydrate,  15  grains,  on  two  occasions,  and  veronal, 
10  grains,  once.  His  coughing  was  relieved  by  j  grain  of  codein,  and 
his  bowels  were  kept  regular  by  A,  S.  and  B.  pills.  After  the  first  few 
days  he  was  able  to  be  up  and  out-of-doors,  and  gained  considerably  in 
strength. 

Diagnosis. — Phthisis. 

Case  103 

An  English  tailor  thirty-eight  years  of  age,  who  entered  the  hos- 
pital ISIarch  11,  1908,  had  been  complaining  of  pains  throughout  his 
body,  especially  in  his  lower  legs,  for  the  past  seven  weeks.  The 
pains  were  so  severe  as  to  compel  him  to  give  up  work,  but  were 
relieved  by  treatment.  Three  days  ago  he  began  to  have  pain  in 
the  right  upper  quadrant,  radiating  to  other  parts  of  the  abdomen  and 
downward.  His  appetite  has  Ijcen  poor,  but  he  has  not  vomited.  His 
bowels  have  been  moved  by  cathartics.  Tliree  days  ago  he  had  two 
severe  chills,  and  since  then  he  has  sweat  a  good  deal  at  times. 
Nothing  aljnormal  was  noticed  al:)out  his  water. 

Physical  examination  revealed  nothing  wrong  in  the  chest.  The 
abdomen  was  full,  tympanitic  throughout,  and  held  rather  rigidly. 
The  patient  appeared  to  sulTcr  a  good  deal  of  pain,  but  when  his  atten- 
tion was  distracted,  one  could  palpate  deeply  without  discovering  any 
tenderness.  Attempts  to  mo\-e  the  bowels  were  not  satisfactory.  The 
leukocyte  count  at  entrance  was  14,000;  next  day  it  had  risen  to  21,000. 
and  on  the  third  day  to  25,200.  His  temperature  ranged  l)etween  101° 
and  102°  F. ;  his  pulse,  between  90  and  100.  His  urine  showed  nothing 
aljnormal. 

Discussion. — The  patient's  account  of  himself  leaves  us  still  in  the 
dark  as  to  the  nature  of  his  trouble.  Disco\ering  that  his  abdominal 
tenderness  ap])arcntly  disa])pears  when  his  attention  is  distracted,  we 
are  in  danger  of  discounting  his  other  and  more  serious  symj^toms. 
But  with  pain,  chills,  and  an  increasing  leukocytosis  there  is  almost 
certainly  a  focus  of  infection  somewhere.  Our  l)est  guide  in  all  proba- 
l)ility  is  the  initial  ])ain,  since  he  has  not  yet  arri\ed  at  that  third  stage 
in  tlie  development  of  an  infection  at  which,  after  scattering  itseh"  in 
confusing  radiations,  the  ])ain  and  tenderness  llnally  "settle"  ()\"er 
the  site  of  the  disease.      (See  further  discussion  of  this  poiiit'on  ]).  207.) 

There  is  notliing  in  the  data  liere  presented  to  incriminate  the 
kidney  or  the  stomach.  On  the  wliole,  therefore,  tiie  most  likely  place 
for  investigation  is  the  gall-bladder.  Xe\ertheless.  there  are  many 
other  possibilities.     1  ha\'e  seen  a  case  much  like  this  in  which  tiirom- 


220  DIFFERENTIAL  DIAGNOSIS 

bosis  of  a  mesenteric  artery  was  found  at  operation,  but  I  have  never 
known  that  diagnosis  correctly  made  before  operation.  Appendicitis 
and  portal  phlebitis  are  also  possible. 

Outcome. — Laparotomy  on  the  thirty-first  revealed  an  acute  chole- 
cystitis. 

Diagnosis. — Acute  cholecystitis. 

Case  104 

A  Hungarian  woman  of  sixty  entered  the  hospital  August  22,  1907, 
complaining  of  two  months'  pain  in  the  right  upper  quadrant  of  the 
abdomen,  but  asserting  that  her  sickness  was  wholly  due  to  the  behavior 
of  her  step-daughter.  As  a  result  of  this  the  patient  has  lost  her  appetite, 
become  constipated  and  rather  sleepless,  but  has  not  given  up  work. 
She  has  had  five  children  and  no  miscarriages,  and  has  always  con- 
sidered herself  well.  She  passed  the  menopause  twenty  years  ago; 
her  past  history  and  family  history  have  been  w^holly  good. 

On  examination  she  was  found  to  be  decidedly  pale.  There  was 
no  glandular  enlargement.  There  was  ptosis  of  the  left  upper  eyelid, 
but  the  eyes  were  otherwise  normal  except  for  marked  irregularity  of 
the  pupils  and  a  failure  to  react  to  light.  The  chest  revealed  nothing 
abnormal.  The  abdomen  was  large  and  flabby.  The  whole  of  the 
right  half  of  it  was  occupied  by  a  hard,  smooth,  irregular  mass,  immova- 
ble, not  tender,  and  very  sharp  at  the  edge.  The  dulness  over  this 
area  was  continuous  with  the  liver  dulness,  which  began  at  the  sixth 
rib.  The  lower  border  of  the  tumor  was  six  inches  below  the  costal 
margin  (Fig.  34).  There  were  slight  edema  along  the  shins  and  marked 
varicosity  of  the  veins  in  both  legs. 

The  hemoglobin  was  20  per  cent.;  leukocytes,  2000;  the  urine 
normal.  Vaginal  and  rectal  examinations  were  negati^■e.  The  gastric 
contents  extracted  after  a  test-meal  showed  no  free  hydrochloric  acid 
and  no  occult  blood.  The  capacity  of  the  stomach  was  50  ounces. 
There  was  no  residue  before  breakfast. 

Discussion.^The  problem  here  is  of  a  tumor  in  the  right  hypo- 
chondrium  with  anemia — a  tumor  which  gives  every  evidence  of  being 
coarsely  irregular  in  shape.  Under  these  conditions  the  possibilities  for 
diagnosis  are  as  follows: 

(a)  Liver — cancer,  syphilis;  much  less  probably  hydatid,  enlarged 
gall-bladder,  downward  displacement  of  the  normal  organ. 

(b)  Kidney — tuberculosis,  hydronephrosis  or  pyonephrosis,  cystic 
degeneration,  neoplasm. 

(c)  Retroperitoneal  tumors  displacing  or  pushing  forward  the  liver. 


i'ig.  3|. — Outlines  of  a  mass  ffit  in  Case  104.     Chief  comjilaint  is  ])ain  in  llie  rij^ht  hypo- 

chon(hiinn. 


RIGHT   HYPOCHONDRIAC    PAIN  221 

Tumors  of  the  stomach  or  intestine  are  practically  out  of  the  ques- 
tion. Masses  of  exudate  and  matted  intestines,  such  as  occur  with 
tuberculous  peritonitis,  are  smaller  and  have  no  sharp  edge. 

Returning,  then,  to  the  three  main  groups  listed  above,  we  may 
exclude  displacements  of  the  liver  and  enlargements  of  the  gall-bladder, 
since  the  shape  of  the  tumor  here  present  does  not  correspond  at  all 
with  any  of  these. 

Hydatid  cysts  of  the  liver  do  not  produce  so  grave  an  anemia  and 
are  usually  large  enough  to  be  perceptible  by  the  individual  and  com- 
plained of  by  him  before  the  physician  discovers  them.  This  patient 
was  wholly  unaware  of  her  tumor. 

Cancer  and  syphilis  of  the  liver  remain  as  possibilities,  to  the  dis- 
cussion of  which  we  shall  return  presently. 

Of  the  tumors  connected  with  the  kidney,  those  due  to  tuberculosis 
are  perhaps  the  commonest.  They  almost  invariably  produce  pyuria 
and  bladder  symptoms,  which  are  not  present  here.  Further,  the  shape 
of  this  mass  and  its  position  in  the  abdomen  are  not  at  all  characteristic 
of  tumors  originating  in  the  kidney.  Fever  and  pain  would  also  be 
expected  in  a  patient  suffering  from  renal  tuberculosis,  though  these 
symptoms  arc  less  constant  than  those  above  mentioned. 

Hydronephrosis  and  j)yonephrosis  produce  smooth,  rounded  tumors, 
usually  elastic  in  feel,  and  more  deeply  situated  in  the  loin  than  the 
mass  here  in  question.  They  often  appear  intermittently,  their  dis- 
appearance being  accompanied  by  an  increased  flow  of  urine. 

Cystic  kidneys  are  practically  always  congenital  and  bilateral. 
They  are  not  associated  with  anemia ;  indeed,  none  of  the  renal  lesions 
hitherto  mentioned  produces  any  considerable  anemia  in  the  great 
majority  of  cases. 

New-growths  of  the  kidney  may  ])roduce  grave  anemia,  but  when 
this  is  the  case,  they  are  practically  always  associated  with  hematuria, 
which  has  been  absent  here. 

Retrojieritoneal  tumors  originating  in  tlie  T)re\"ertebral  glands  occa- 
sionally ])resent  a  picture  much  like  that  here  seen.  The  fact  that  the 
tumor  is  immo\able  tends  to  idcnlif}'  it  with  a  retroperitoneal  structure, 
rather  than  with  the  ]i\er.  Not  infrefjuently  these  rctro])eritoneal 
tumors  displace  the  li\er  do\\'n\var(i  and  forward,  so  that  what  our 
hands  feel  is,  in  fact,  not  the  new-growth  itseh",  but  ihv  normal  H\rr. 
I  ha\'e  taken  ])art  in  h)ng  and  fruitless  discussions  as  to  wliat  (li>t'a>c 
of  the  Vwvv  is  ])rcscnt  in  a  case  of  tlii^  kind,  only  to  (iisco\er  al  oiuration 
or  autopsy  that  we  have  been  suspecting  the  wrong  organ.     The  nodular 


222  DIFFERENTIAL   DIAGNOSIS 

surface  of  the  growth  from  which  this  woman  is  suffering  excludes  the 
latter  possibility. 

The  tumor  is  certainly  not  the  normal  liver:  it  is  either  a  diseased 
liver  or  a  new-growth  arising  elsewhere. 

With  these  possibilities  in  mind  we  return  to  the  general  study  of 
the  case,  and  are  struck  by  the  fact  that  the  patient  has  a  ptosis  and 
pupils  unresponsive  to  light,  both  of  which  symptoms  are  characteristic 
results  of  old  syphilis.  This  naturally  makes  us  inclined  to  follow  up 
the  clue  and  try  the  therapeutic  test.  A  course  of  iodid  and  mercury 
will  do  no  harm  to  any  malignant  new-growth,  and  will  probably  produce 
marked  improvement,  local  and  general,  if  the  liver  be  syphilitic. 

Outcome. — Under  mercurial  inunctions  and  potassium  iodid,  5  to  50 
grains,  the  patient  improved  very  markedly  in  ten  days,  and  the  size  of 
the  tumor  rapidly  decreased.  Except  for  occasional  doses  of  veronal,  5 
grains,  and  the  painting  of  a  25  per  cent,  alcoholic  solution  of  menthol 
over  the  epigastrium  for  the  relief  of  pain,  no  other  medication  was  given. 

Diagnosis. — Hepatic  syphilis. 

Case  105 

A  Russian  Jewess  of  forty-two  has  been  complaining  for  eighteen 
months  of  a  burning  pain  in  the  right  upper  quadrant,  almost  constant, 
often  keeping  her  awake,  sometimes  shifting  into  the  back,  but  never 
colicky  or  paroxysmal.  She  has  vomited  occasionally,  but  has  ne^'er 
been  jaundiced.  For  the  same  period  she  has  had  distress  across  the 
upper  half  of  the  abdomen  after  meals,  with  belching  and  constipation, 
her  bowels  moving  only  every  four  or  five  days.  For  three  months  all 
these  symptoms  have  been  aggravated,  and  she  has  vomited  green 
materia]  nearly  every  day.  She  has  never  vomited  any  blood  or  any 
food.  She  thinks  she  has  lost  much  Vv'eight.  She  has  no  appetite 
and  has  been  in  bed  much  of  the  time  of  late. 

The  patient  was  obese,  the  chest  negative,  the  abdominal  wall  loose, 
flabby,  and  soft.  The  right  kidney  could  be  felt  at  three  fingers'  breadth 
below  the  ribs,  and  the  edge  of  tlie  liver  was  also  palpable.  Physi- 
cal examination,  including  the  blood,  pulse,  temperature,  respiration, 
and  blood-pressure,  was  normal.  The  urine  ranged  between  25  and  35 
ounces  in  twenty-four  hours,  with  a  specific  gravity  from  1012  to  1019; 
there  were  very  slight  traces  of  albumin  and  a  few  hyaline,  granular, 
and  brown  granular  casts.  Examination  of  the  stomach-contents  and 
of  the  stools  revealed  nothing  abnormal. 

Discussion. — When  a  Russian  Jew  complains  of  a  ''burning  pain," 
it  usually  turns  out,  on  closer  questioning,  that  he  has  a  Ixirning  and 


RIGHT   HYPOCHONDRIAC    PAIN 


223 


not  a  pain.  The  word  "burning"  (brennend)  is  used  by  the  Jews  far 
more  often  in  describing  their  symptoms  than  by  any  other  race,  and,  as 
a  rule,  patients  who  use  this  term  turn  out  to  be  free  from  organic  disease. 
Whether  it  is  a  cutaneous  paresthesia  connected  with  nervous  dcbihty, 
or  whether  it  is  connected  with  gastric  stasis  and  fermentation,  is  often 
very  difficult  to  determine. 

Gastric  symptoms  appearing  for  the  first  time  in  a  person  over  forty 
always  make  us  think  of  cancer  of  the  stomach,  but  if  that  disease  had 
existed  for  eighteen  months,  we  should  be  almost  certain  to  find  stasis, 
emaciation,  or  anemia.  Peptic  ulcer  cannot  be  ])Ositively  excluded, 
but  the  symptoms  are  not  definite  enough  to  warrant  our  beginning 
treatment  for  that  affection  until  more  probable  alternatives  have  been 
tried  out. 

The  palpable  kidney  and  the  presence  of  albumin  and  casts  in  the 
urine  make  it  our  duty  to  consider  whether  the  symptoms  may  be  due 
to  some  form  of  renal  disease.  These  symj)toms  could  ])e  ])roduced  by  the 
kidney  if  the  latter  exerted  direct  pressure  upon  the  pylorus  or  intestine, 
so  as  to  retard  their  movements  in  the  course  of  digestion.  But  this 
seems  very  unlikely  in  view  of  the  moderate  size  and  free  mobility  of 
the  organ.  The  kidney  might  also  ])c  res])onsible  for  suffering  like 
that  here  described  if  it  were  the  seat  of  a  chronic  nephritis  with  uremia, 
but  the  normal  condition  of  the  heart  and  blood-pressure  makes  this 
unlikely,  and  the  urine  is  not  at  all  typical  of  acute  nephritis. 

Evidently  the  ])aticnt  has  a  general  visceroptosis,  and  this,  with 
her  obesity,  her  incom])etent  abdominal  muscles,  and  her  constipation, 
might  well  be  sufiicient  to  account  for  her  com])laints. 

It  may  be  well  to  say  a  word  here  aljout  the  psychic  significance 
of  green  vomiting.  Of  course,  e\ery  i)hysician  is  aware  tliat,  from 
the  ])h}'sical  point  of  \-iew,  any  long-continued  or  \iolent  xoniiting 
])roduces  green-colored  \"omitus  througli  the  comj^ression  exerted  upon 
tile  gall-bladder  b}'  the  abdominal  walls.  l)Ut  in  the  patient's  mind 
green  \T)miting  has  often  a  dark  and  terrif}ing  significance,  so  that 
it  is  well  explicitly  to  reassure  an}'  patient  who  complains  of  this  s}"mptoni, 
remembering  that  he  does  not  share  our  understandinir  of  its  harm- 
lessness. 

Outcome. — A  snugly  fitting  abdominal  liandage  ga\e  the  j-atieiit 
\'erv  marked  relief,  and  when  her  bowels  had  been  regulated  by  the 
use  of  c;domel,  '•  grain  ex'e'-v  fifteen  minuti'S  until  ten  doses,  lolhn-.ed 
in  ha.lf  an  hour  b\-  a  seidlit/  po\\"(ler  and  thereafter  b\'  easeara,  she  ^'.as 
able  to  leave  the  hospital,  nuieh  relie\ed,  at  the  end  ot  two  wiiks. 

Diagnosis. — Ilanizebauch. 


224  DIFFERENTIAL  DIAGNOSIS 

Case  106 

A  carpenter  of  fifty-four  entered  the  hospital  June  19,  1908,  with 
the  statement  that  six  weeks  ago,  while  at  work,  he  had  a  sudden  attack 
of  pain  in  the  right  upper  quadrant,  radiating  to  the  right  shoulder.  This 
pain  was  relieved  by  a  hot  drink,  and  disappeared  in  about  three  hours. 
He  vomited  once  that  night.  He  went  to  work  the  next  morning.  A 
week  later  the  pain  returned,  and  it  has  since  been  nearly  continuous, 
though  for  the  past  two  days  it  has  been  less  severe.  At  the  onset  it  was 
accompanied  by  a  swelling  of  the  abdomen  and  by  jaundice.  He 
has  had  dark  urine,  light  stools,  and  much  itching  for  the  past  five 
weeks.  Fever  and  vomiting  ha\'e  been  absent.  His  appetite  has  been 
poor,  and  he  has  had  moderate  constipation. 

On  examination,  moderate  Jaundice  and  marks  of  scratching  were 
everywhere  evident.  The  chest  was  normal.  The  abdomen  showed 
tenderness  in  the  epigastrium  and  for  se\'eral  inches  to  the  right  of  this 
point.  The  upper  right  rectus  was  more  resistant  than  the  left.  The 
edge  of  the  liver  could  be  felt  an  inch  and  a  half  below  the  rib  margin. 
The  patient  has  lost  42  pounds  in  the  past  eight  weeks. 

Discussion. — The  diagnostic  problem  confronting  us  concerns  the 
cause  of  emaciation,  jaundice,  steady  pain,  and  enlargement  of  the  liver 
in  a  man  of  fifty-four.  Cancer  of  the  pancreas  or  of  some  portion  of  the 
bile-ducts  would  produce  all  these  symptoms,  and  is  their  commonest 
cause  in  men  of  this  age,  but  it  is  hard  to  understand  why  any  of  these 
lesions  should  produce  so  sudden  an  attack  of  pain  and  of  jaundice. 
The  supposed  cause — cancer — being  an  affair  of  gradual  growth,  one 
would  expect  the  symptoms  to  develop  gradually,  not  suddenly.  Ne\'er- 
theless,  clinical  experience  has  shown  that  cancer  may  manifest  itself 
suddenly,  and  with  the  symptoms  here  described.  We  must  face  the 
fact,  whether  we  understand  it  or  not.  Against  cancer  is  the  ab- 
sence of  an  enlarged  gall-bladder,  which  is  the  rule  when  cancer 
obstructs  the  bile-ducts.  But  this  objection  is  not  sufficient  to  make 
us  certain  that  cancer  is  not  present.  The  possibility  must  still  be 
entertained. 

Stone  in  the  common  duct  might  produce  all  the  symptoms  under 
discussion,  and  would  account,  better  than  cancer  does,  for  the  sudden 
onset  and  the  biliary  colic.  The  loss  of  42  pounds  in  eight  weeks  as 
a  result  of  cholelithiasis  alone  is  at  first  sight  astounding,  but  experience 
shows  that  it  is  not  at  all  unusual.  More  unexpected  is  the  absence 
of  fever,  chills,  vomiting,  and  of  variations  in  the  intensity  of  the  jaundice, 
all  of  which  are  the  rule  when  a  stone  blocks  the  common  duct.     The 


RIGHT  HYPOCHONDRIAC   PAIN  22$ 

moderate  degree  of  jaundice,  on  the  other  hand,  favors  stone  rather  than 
cancer. 

ObUteration  of  the  bile-ducts  by  the  scar  of  an  inflammator}'  process, 
due  to  syphiHs  or  some  other  cause,  is  a  very  rare  lesion.  It  is  usually 
gradual  in  onset  and  does  not  produce  sharp  pain. 

Nothing  is  said  in  the  history  about  the  patient's  habits.  If  we 
choose  to  assume  that  he  was  a  confirmed  alcoholic,  his  jaundice  might 
be  due  to  cirrhosis  of  the  liver,  especially  as  the  edge  of  that  organ  is 
easily  palpable.  The  sudden  pain,  however,  could  hardly  be  due  to 
cirrhosis,  and,  as  the  case  stands,  we  have  nothing  to  support  such  a 
hypothesis.    The  habits  should  be  further  investigated. 

On  the  whole,  the  diagnosis  must  remain  in  doubt  as  between  stone 
and  cancer,  the  odds  slightly  favoring  stone. 

Outcome. — On  the  twenty-second  of  June  the  abdomen  was  opened 
and  two  large  stones  were  removed  from  the  common  bile-duct.  The 
patient  made  an  uneventful  recovery. 

His  itching  was  relieved  by  a  powder  consisting  of  sodium  salicylate, 
talc,  and  starch  in  equal  parts,  dusted  on  the  skin,  and  also  by  an  alkaline 
bath. 

Diagnosis. — Stone  in  ductus  choledochus. 

Case  107 

An  unmarried  w'oman  of  twenty-nine  entered  the  hospital  March 
II,  1908.  Since  the  age  of  sixteen  she  has  had  at  times  "stoppage  of 
the  bowels,"  worse  when  she  is  on  her  feet.  When  questioned  as  to 
the  nature  of  this  stoppage,  she  stated  that  it  consisted  of  pain  in  the 
right  upper  quadrant,  so  se\'cre  that  she  cannot  stand  the  pressure  of 
her  clothes,  accompanied  In'  the  i)resence  of  a  lump  which  is  more 
prominent  when  she  exercises.  This  trouble  has  been  especially  bad 
for  the  past  fi\e  months.  Her  bowels  rarely  move  without  medicine, 
and  her  stools  are  small,  hard,  and  often  black.  She  has  a  poor  appetite, 
but  never  vomits.  She  had  considerable  cough  and  sputa  off  and  on  for 
years,  l)ut  has  never  raised  blood.  For  four  months  she  has  had  much 
dyspnea  and  pal])itation.  Her  urine  is  at  times  scanty,  never  bloody, 
and  never  passed  in  large  amounts.  She  has  lost  li\e  pounds  in  the 
last  two  years. 

The  patient  is  pale  (hemoglol)in,  75  per  cent.).  Scattered  on  tlie 
right  half  of  tiie  trunk  and  the  inner  as])cct  of  th.e  right  upjx-r  arm  are 
numerous  light-brown,  irregularly  siiaped  spots.  The  glands  ;ire 
pal{)a1)le  in  the  axilkc  and  groins.  The  tongue  is  ])at  sha]H'(l — \\i<Kst 
at  the  tip.  It  is  protruded  very  far,  and  during  tliis  act  the  anttrior 
1", 


2  26  DIFFERENTIAL   DIAGNOSIS 

pillars  of  the  fauces  are  drawn  forward.  A  low-pitched  systolic  murmur 
is  heard  over  all  the  precordia,  but  not  transmitted  beyond  that  area. 
The  heart  shows  no  enlargement.  The  pulmonic  second  sound  is 
greater  than  the  aortic  second.  In  the  epigastrium  a  violent  pulsation, 
vertical  and  lateral,  is  felt,  raising  the  hand  three-quarters  of  an  inch 
at  each  beat  of  the  heart.  Beneath  the  margin  of  the  right  ribs  a 
smooth,  rounded  mass,  about  four  inches  long  and  two  inches  wide, 
can  be  grasped  between  the  hands  and  moved  about  in  all  directions. 
It  is  very  tender. 

Discussion. — The  points  deserving  discussion  in  this  case  are  the 
nature  of  the  "stoppage  of  the  bowels,"  the  interpretation  of  the  heart 
murmur  in  connection  with  the  patient's  dyspnea  and  palpitation,  the 
significance  of  the  way  in  w^hich  the  tongue  is  protruded,  the  nature 
of  the  rash  upon  the  chest,  and  the  importance  of  the  mass  in  the  right 
hypochondrium. 

It  is  clear  that  she  has  no  stoppage  of  the  bowels.  We  have  to 
explain,  however,  why  the  lump  complained  of  in  the  upper  right  quad- 
rant and  the  pain  which  accompanies  it  are  more  prominent  on  exer- 
tion. This  is  the  case  not  infrequently  with  a  tender,  passively  congested 
liver,  the  result  of  cardiac  insufficiency.  But  have  we  any  such  insuf- 
ficiency in  this  case? 

Since  the  heart  is  not  enlarged  and  the  pulmonic  second  sound  no 
louder  than  we  should  expect  it  to  be  in  a  woman  of  twenty-nine,  we 
have  only  the  murmur  to  suggest  heart  disease.  But  from  a  systolic 
murmur  alone  it  is  never  wise  to  infer  the  presence  of  any  disease  of 
the  heart,  especially  when  the  patient  is  anemic.  It  seems  reasonable 
to  consider  this  murmur  as  hemic  or  functional.  We  have  no  reason, 
then,  to  believe  that  the  heart  is  failing  or  that  the  lump  in  the  right 
upper  quadrant  has  any  relation  to  it. 

A  patient  who  protrudes  his  tongue  in  the  way  described  above, 
so  that  the  whole  of  it  can  be  seen,  has  usually  been  in  the  ha1)it  of 
looking  at  his  tongue  in  a  mirror.  The  pillars  of  the  fauces  are  then 
drawn  forward  by  the  effort  to  get  the  tongue  completely  into  the  outer 
world.  These  facts  give  us  a  certain  inkling  of  the  jmtient's  mental 
condition  and  of  its  possible  bearing  on  the  interpretation  of  his  symp- 
toms. 

The  eruption  here  described  seems  to  correspond  with  that  produced 
by  tinea  versicolor.  Though  other  possibiHties  are  open,  this  seems 
the  most  reasonable  one,  provided  the  lesions  are  of  long  standing. 
This  is  the  most  common  position  for  an  eruption  of  that  origin. 

The  mass  in  the  right  hypochondrium  corres])onds  accurately  to 


RIGHT   HYPOCHONDRIAC    PAIN  227 

the  description  of  a  floating  kidney,  though  not  all  such  kidneys  are 
tender.  It  is  probably  the  lump  which  the  patient  felt  at  the  times  when 
she  supposed  herself  to  have  stoppage  of  the  bowels.  This  would 
account  for  its  greater  prominence  when  she  is  on  her  feet. 

The  association  of  floating  kidney  with  a  great  variety  of  so-called 
neurasthenic  symptoms  is  a  very  familiar  fact  clinically.  That  this 
patient  is  of  a  neurotic  temperament  is  suggested  by  the  violent  beating 
of  the  abdominal  aorta  (dynamic  aorta),  by  the  way  she  puts  out  her 
tongue,  and  by  her  chronic  constipation.  In  the  absence  of  any  other 
lesions  discoverable  on  physical  examination  the  diagnosis  of  floating 
kidney  associated  with  slight  anemia  in  a  neurotic  person  seems  the  best 
explanation  of  the  symptoms.  The  dyspnea  may  well  be  due  to  the 
anemia. 

Outcome. — The  patient  was  given  a  close-fitting  abdominal  binder, 
which  apparently  gave  much  relief.  Reassurance  and  general  tonic 
treatment  (Blaud's  pill,  10  grains  thrice  daily,  tincture  of  nux  vomica, 
10  to  50  drops  before  each  meal)  played  a  large  part  in  her  recovery. 

Diagnosis. — Del)ility;  floating  kidney. 

Case  108 

An  American  woman  of  forty-six  has  been  doctoring  for  stomach 
trouble  for  five  months.  A  month  ago  she  was  taken  suddenly  with  a 
profuse  black,  watery  diarrhea.  This  was  followed  by  vomiting,  chills, 
and  pain  in  the  epigastrium  and  back.  For  a  week  she  was  kept  more 
or  less  under  opium,  after  which  the  gastric  and  intestinal  symptoms 
abated,  but  she  has  remained  in  l:)cd  most  of  the  time  since  then,  in  a 
very  exhausted  condition,  and  suffering  most  of  the  time  from  pain  in 
the  right  upper  quadrant  and  in  the  small  of  the  ];ack.  This  jKiin  is 
constant,  with  occasional  exacerbations.  Oj)ium  has  frequently  been 
given.  For  several  wecl;s  she  has  taken  only  licjuids.  Altliough  the 
y)ain  appears  only  in  relation  to  eating,  slie  vomits  nearly  every  day  at 
irrregular  intervals.  She  has  never  vomited  blood,  and  has  ne\"er  l^een 
jaundiced.  She  has  had  a  slight  cou<i;h  for  ii\e  years,  and  dxspnea 
on  exertion  for  one  year.  She  has  lost  t  :;  pounds  in  tlie  past  two  years. 
The  |)a!n  is  often  severe  enough  to  keej)  her  awake  at  night. 

On  ])]iysical  examination  the  mucous  membranes  arc  found  jvale. 
The  chest  is  negative,  excei)t  for  slightlv  diminished  res])iration  in  the 
right  back,  below  midscapula.  The  abdomen  is  entirely  negaliw.  iwctpi 
that  the  edtre  of  the  liver  is  palT)al)le  on  deep  inspiration. 

The  blood  shows  red  cells,  4,032,000;  white  cells,  6S00;  heinogloljin, 
55  per  cent. 


228  DIFFERENTIAL  DIAGNOSIS 

The  stained  smear  shows  some  achromia  and  poikilocytosis.  The 
differential  count  and  the  other  features  of  the  blood  are  normal.  Care- 
ful examination  in  a  warm  bath,  with  complete  and  satisfactory  relaxa- 
tion of  the  abdominal  muscles,  shows  absolutely  nothing  abnormal. 
Examination  of  the  stomach  shows  no  fasting  contents.  The  gastric 
capacity  is  36  ounces — the  lower  border  of  the  organ  one  inch  below 
the  navel  after  inflation.  After  a  test-meal  no  free  hydrochloric  acid 
and  no  organic  acids  are  found.  The  guaiac  test  is  negative  in  the 
gastric  and  intestinal  contents. 

After  three  weeks'  stay  in  the  hospital  the  patient  gained  three  pounds, 
but  continued  to  complain  of  pain  and  seemed  very  miserable. 

Discussion. — The  black  color  of  the  stools,  associated  with  a  long- 
continued  gastric  disturbance,  forms  an  important  portion  of  the  picture 
of  peptic  ulcer.  We  must  remember,  however,  that  as  she  has  been 
doctoring  for  stomach  trouble  for  five  months  and  has  taken  a  great 
deal  of  opium,  it  is  quite  possible  that  her  symptoms  may  be  due  wholly 
or  in  part  to  the  treatment.  Black  stools  may  well  be  due  in  this  case 
to  that  commonest  of  gastric  medicaments,  subnitrate  of  bismuth.  In 
patients  who  have  been  through  five  months  of  this  kind  of  treatment 
it  is  not  at  all  surprising  to  find  hydrochloric  acid  absent  from  the  gastric 
contents.  Her  stomach  empties  itself  normally,  shows  no  enlargement 
and  no  blood.  One  more  point  serves  to  increase  our  confidence  that 
no  visceral  disease  is  present,  namely,  the  complaint  of  a  year's  dyspnea 
by  a  patient  whose  heart  and  lungs  are  normal.  This  dyspnea  ante- 
dates the  occurrence  of  stomach  symptoms  by  at  least  se^"en  months. 
This  would  be  quite  natural  if  we  supposed  that  the  dyspnea  and  the 
stomach  symptoms  were  alike  due  to  the  anemia  shown  by  the  present 
blood  examination.  If,  on  the  other  hand,  the  anemia  resulted  through 
hemorrhage  from  an  ulcer,  the  dyspnea  should  not  have  antedated  the 
stomach  symptoms. 

Yet,  after  the  use  of  treatment  based  upon  the  idea  that  anemia  was 
the  cause  of  her  symptoms,  there  was  no  clear  proof  that  we  were  right 
and  it  seemed  best  to  explore  the  abdomen. 

Outcome. — Operation  by  Dr.  F.  B.  Harrington  revealed  absolutely 
nothing,  but  the  patient  seemed  greatly  improved  ajter  it,  and  when 
last  heard  Jrom  had  continued  in  good  health.  Cases  of  this  type 
should  be  borne  in  mind  when  discussion  arises  regarding  those  opera- 
tions for  "chronic  appendicitis"  in  which  the  appendix  shows  signs  of 
appendicitis  only  to  the  eye  of  the  surgeon,  while  the  pathologist  remains 
unconvinced. 

"But  the  patient's  symptoms  abated  after  the  operation,"  says  the 


Fig.  35. — Diagram  of  bulging  and  resistance  as  recorded  in  Case  109.     Symptoms,  pain 
over  the  above  area,  weakness,  dyspnea,  and  cough.     (See  also  Pig.  36.) 


Fig.  36. — Signs  discovered  in  the  Ijack  of  patient  descril)ed  on  i)agc  229.     (See  also  Fig.  35.) 


RIGHT   HYPOCHONDRIAC   PAIN  229 

surgeon.  True,  but  so  they  did  in  the  case  just  described,  though 
nothing  was  removed.  There  is  abundant  experience  to  prove  that 
operations  and  postoperative  hygiene  (mental  and  physical)  are  in 
themselves  enough  to  produce  a  marked  improvement  in  the  symptoms 
of  many  a  patient. 

Diagnosis. — Debility. 

Case  109 

March  i8,  1907,  I  examined  a  Russian  tailor  thirty-nine  years  old, 
with  the  history  of  pain  in  the  right  upper  quadrant  lasting  fifteen 
weeks,  accompanied  by  frequent  dry  cough,  shortness  of  breath,  and 
increasing  weakness,  but  no  fever,  so  far  as  he  knows.  For  the  past 
two  weeks  he  has  had  night-sweats,  tenderness  in  the  left  shoulder, 
and  inability  to  sleep  on  the  left  side.  He  has  lost  weight  and  strength, 
but  has  worked  irregularly  until  two  weeks  before  entrance.  His 
previous  history,  family  history,  and  habits  are  otherwise  excellent. 

Examination  showed  a  sallow,  emaciated,  worn-looking  man. 
Nothing  abnormal  was  detected  in  the  examination  of  the  heart.  In 
the  right  back  there  was  dulness  below  the  angle  of  the  scapula,  with 
diminished  breath  and  voice-sounds.  The  condition  of  the  abdomen 
is  best  explained  by  Fig.  35. 

The  patient's  temperature  ranged  for  eight  days  between  99°  and 
101°  F.  His  red  cells  were  4,000,000;  white  cells,  11,000;  hemoglobin, 
60  per  cent.  The  stained  smear  showed  nothing  abnormal.  The  urine 
was  equally  blameless.  In  the  stools  numerous  eggs  of  the  Trichuris 
trichiuria  were  found.  Rather  large,  palpable  glands  were  found  above 
both  clavicles;  the  chest,  head,  and  extremities  negative,  excc])t  as 
above  noted.     Free  purgation  produced  no  change  in  the  physical  signs. 

Discussion. — There  is  a  good  deal  to  suggest  phthisis  in  the  first 
impression  of  this  case — cough,  dysfmca,  weakness,  night  sweats. 
But  though  there  are  some  abnormal  signs  in  the  right  back,  they  arc 
not  sufiicient  to  account  for  the  symptoms.  Fmpyema  is,  perha]:)s, 
more  likely,  but  I  have  never  heard  of  an  emj)ycma  which  worked  to 
the  surface  so  near  the  ensiform  cartilage.  It  is  inifortunate  that  an 
.v-ray  was  not  taken,  owing  to  the  ])atient's  great  iirostraliou.  By  this 
means  one  might  have  o])taine(l  some  e\i(lence  as  to  whether  the  troubk- 
was  above  or  below  the  diaphnigm.  Our  attention  naturally  renters 
on  the  region  of  the  ])roniinence  shown  in  Fig.  :;5;  at  hrst  sight  tlu- 
mass  certainly  appears  to  be  belo.v  the  diaphragm. 

Tumors  of  the  li\-er  should  first  engage  attention.  Cancer  of  the 
li\er  almost  ne\"er  presents  itself  in  this  situation  onlw      We  iind  almost 


23Q  DIFFERENTIAL   DIAGNOSIS 

invariably  a  general  enlargement  of  the  liver  downward,  and  multiple 
nodular  masses  below  the  ribs.  I  have  never  known  a  hepatic  cancer 
to  produce  a  localized  bulging  of  the  chest-wall  such  as  was  present  in 
this  case.  This  latter  observation  applies  also  to  tumors  of  the  colon, 
gall-bladder,  retroperitoneal  glands,  and  kidney.  The  hypothesis  of 
cancer  somewhere  receives  some  support  from  the  presence  of  enlarged 
glands  over  the  clavicle,  which  might  represent  metastases;  but  it  is 
very  hard  to  see  where  the  cancer  could  be  situated. 

Hydatid  cyst  of  the  liver  was  much  discussed  in  the  numerous  bed- 
side consultations  over  this  case,  but  it  was  pointed  out  that  hydatid 
does  not  produce  so  much  prostration  and  pain,  not,  at  any  rate,  until 
it  has  produced  a  tumor  much  larger  than  that  in  this  present  case. 
The  striking  thing  about  most  hydatid  cysts  of  the  liver  is  the  slight 
impression  that  they  seem  to  make  either  upon  the  patient's  conscious- 
ness or  upon  his  general  health  and  nutrition.  The  feel  of  the  tumor 
in  this  case  is  not  at  all  characteristic  of  hydatids. 

Can  local  disease  of  the  chest-wall  explain  these  symptoms?  Tuber- 
culosis, syphilis,  actinomycosis,  or  neoplasm  might  appear  at  this  point, 
but  they  should  involve  the  ribs  or  intercostal  tissues  themselves,  whereas 
in  this  case  the  ribs  seem  to  be  quite  unaffected — merely  pushed  forward 
by  something  behind  them. 

Hepatic  abscess  or  subdiaphragmatic  abscess  often  causes  a  promi- 
nence at  exactly  this  point,  and  some  of  the  symptoms  of  the  case — the 
pain,  cough,  dyspnea,  weakness,  and  night-sweats — could  be  thus  ex- 
plained. On  the  other  hand,  we  have  no  history  of  the  ordinary  causes 
for  either  of  these  varieties  of  abscess — no  dysentery,  no  appendicitis, 
no  peptic  ulcer  or  gall-stones.  It  seems  remarkable,  moreover,  that 
the  leukocytes  should  not  be  more  increased  if  there  is  an  abscess  large 
enough  to  produce  such  a  tumor.  Despite  these  objections,  however, 
the  picture  corresponds  more  nearly  wdth  that  of  subdiaphragmatic 
abscess  than  with  any  other  disease. 

Outcome. — A  week  later  the  patient's  abdomen  was  opened  and  a 
subdiaphragmatic  abscess  found.     Its  source  remained  doubtful. 

Diagnosis. — Subdiaphragmatic  abscess. 

Case  110 

A  fireman  of  fifty-eight  worked  on  the  Panama  canal  in  1904  and 
1905,  but  had  to  return  in  December,  1905,  on  account  of  a  long 
attack  of  dysentery.  Though  always  a  heavy  drinker,  he  was  other- 
wise well  until  May,  1906,  and  then  weighed  212  pounds.  In  May 
irregular  colicky  pains  began  in  the  right  upper  quadrant,  which  were 


RIGHT    HYPOCHONDRIAC    PAIN 


231 


much  worse  at  night  and  which  did  not,  as  a  rule,  bother  him  in  the 
day-time.  At  times  he  suffered  enough  to  require  morphin.  There 
was  no  radiation  and  no  vomiting,  but  there  was  nausea,  and  consider- 
able relief  was  obtained  by  belching  gas.  The  bowels  were  rather 
loose,  and  a  movement  caused  relief  of  pain.  At  times  the  mo\cments 
were  clay  colored;  at  other  times  they  were  brown.  About  June  ist 
the  stools  became  persistently  clay  colored,  the  skin  was  noticed  to  be 
yellow  and  the  urine  dark  colored. 

From  June  ist  until  the  present  time  (August  8th)  he  has  had  no 
pain,  but  to-day  about  noon  he  suddenly  began  to  have  a  series  of  very 
severe  cramps,  vomited  for  the  first  time,  and  had  a 
chill.  His  present  weight  is  161,  a  loss  of  50  pounds, 
but  he  had  been  able  to  work  until  six  weeks  pre- 
viously. 

Inspection  of  the  patient's  body  revealed  nothing 
abnormal  except  intense  jaundice,  with  brownish  mu- 
cous membranes  and  an  increase  of  liver  dulness,  such 
that  the  organ  extended  from  the  fifth  rib  in  the 
nipple-line  to  a  point  one  inch  below  the  costal  margin. 
Below  this  edge  a  soft,  rounded  mass  could  be  made 
out,  about  the  size  of  a  lemon.  The  spleen  was  not 
palpable.  The  white  cells  were  16,600;  hemoglobin, 
90  per  cent.  The  Cammidge  test  was  positive.  In  the 
afternoon  after  entrance  the  ])atient  suddenly  sat  up  in 
bed  and  yelled  with  pain;  it  was  referred  to  the  epi- 
gastrium, and  was,  he  said,  unlike  any  that  he  had  had 
before.  The  abdomen  was  now  rigid  throughout,  with 
marked  tenderness,  especially  in  the  epigastrium.  The 
patient  vomited  several  times  this  afternoon. 

Discussion. — A  history  of  dysentery  and  a  residence  in  the  tropics, 
when  followed  by  sym])toms  which  a])pear  to  involve  the  liver,  should 
always  remind  us  that  hepatic  abscess  is  a  common  complication  of 
tropical  dysentery.  This  idea  seems  all  the  more  plausible  in  the 
y^resent  case,  because  there  have  been  chills,  fever,  leukocytosis,  and  an 
increase  of  liver  dulness.  Yet  the  pain  of  hejmlic  abscess  could  rarely 
be  described  as  "cramps."  The  disease  is  often  painless;  if  there  is 
any  pain  at  all  it  is  usually  a  steady,  dull,  but  increasing  type.  The 
soft  tumor  Ijelow  the  ribs,  moreover,  cannot  be  due  to  hepatic  ai)srcss. 
and  we  do  not  expect  such  intense  and  ])ersistent  jaundice  as  the 
result  of  that  disease. 

Tlic  colicky  ])ains  and  the  jaundice  might  well  have  been  due  to  a 


Fig.  37. — ("liarl  of 
case  I  ic). 


232  DIFFERENTIAL  DIAGNOSIS 

Stone  in  the  common  duct.  Had  this  stone  been  near  the  entrance  of  the 
cystic  duct,  infection  might  well  have  extended  to  the  gall-bladder. 
Suppurative  cholecystitis  and  final  perforation  of  the  gall-bladder  would 
then  account  for  the  chill  and  intense  pain  on  the  day  of  entrance. 

Against  this  we  have  the  fact  that  a  gall-bladder  which  has  previously 
nourished  stones  is  not  often  so  distensible  as  to  form  a  tumor,  such  as 
projected  below  this  patient's  liver.  The  intensity  and  steady  persistence 
of  the  jaundice  are  also  somewhat  unusual  for  choledochus  stone. 

Cirrhosis  does  not  seem  probable,  though  the  usual  cause  of  that 
disease  appears  to  have  been  operative.  A  pain  like  that  here  described 
is  rarely  if  ever  due  to  cirrhosis,  and  the  jaundice  which  occurs  in  a 
certain  proportion  of  cirrhotic  cases  is  almost  never  intense.  Cancer 
of  the  pancreas  or  of  the  bile-ducts  is  the  commonest  cause  of  intense 
and  persistent  jaundice  in  a  man  of  this  age.  The  tumor  below  the 
ribs  might  be  the  enlarged  gall-bladder  which  generally  results  from 
this  disease.  On  the  other  hand,  the  pain  is  severer  and  more  sudden  in 
its  onset  than  is  to  be  expected  in  cancerous  obstruction  of  the  bile- 
ducts.  The  colic  and  the  variation  in  the  color  of  the  stools  seem  more 
like  cholelithiasis.  No  one  of  these  facts,  however,  excludes  cancer, 
which  seems,  on  the  whole,  the  most  reasonable  diagnosis. 

How  are  we  to  explain  the  chill  and  attack  of  pain  described  in  the 
last  few  lines,  which  are  intended  to  convey  an  idea  of  the  greatest 
possible  severity  of  suffering?  In  my  experience  an  abdominal  pain 
of  this  description,  such  that  the  patient  suddenly  yells  out  in  agony,  is 
almost  always  due  to  one  cause — perforative  peritonitis.  This  might 
be  accounted  for  under  either  of  the  diagnoses  last  discussed;  either 
stone  or  cancer  may  have  caused  ulceration  of  the  ducts  and  set  up  at 
first  a  localized  peritonitis,  which  later  perforated  and  set  free  a  virulent 
fluid  into  an  unguarded  peritoneum. 

Outcome. — He  died  three  days  later.  The  variations  of  his  tem- 
perature are  shown  in  the  accompanying  chart.  He  was  able  to  take 
very  little  food,  and  during  the  last  twenty-four  hours  v/as  delirious. 
Autopsy  showed  cancer  of  the  head  of  the  pancreas,  almost  occluding 
the  common  bile-duct.  The  pancreas  was  practically  destroyed.  The 
gall-bladder  was  enlarged,  much  distended,  not  inflamed,  and  con- 
tained a  single  gall-stone.  There  was  an  extensive  cancerous  infiltra- 
tion of  the  posterior  wall  of  the  stomach.  There  was  also  an  acute 
general  peritonitis, /lOr  which  no  cause  could  hejoundl 

Diagnosis. — Pancreatic  cancer. 


laGHT   HYPOCHONDRIAC   PAIN 


233 


Case  111 


A  negro  of  thirty-five  has  complained  of  steady  pain  in  the  right 
hypochondrium  for  two  months.  This  pain  came  immediately  after 
eating  and  lasted  about  two  hours.  His  appetite  is  good.  His  bowels 
are  constipated,  moving  only  once  in  from  two  to  seven  days  with 
medicine.  He  has  also  suffered  from  numbness  and  tingling  in  his  legs, 
with  weakness,  and  has  had  a  cough  for  the  past  two  weeks,  with  slight 
white  sputum. 

Physical  examination  shows  an  irregular  fever  (see  chart),  the  skin 
very  dry  and  scaling,  the  heart  not  remarkable,  the  lungs  negative. 
There  is  a  nodular  mass  indistinctly  felt  in  the 
right  iliac  fossa,  tender,  but  at  times  difficult 
to  outline.  The  abdomen  is  retracted,  and 
peristalsis  can  be  seen  near  the  navel.  On 
the  left  hand  and  the  dorsum  of  the  right 
foot  are  elevated  areas  of  reddened  skin,  with 
a  pink,  smooth  center,  about  one  inch  in  diam- 
eter. The  chest  is  negative;  likewise  the 
blood  and  urine. 

Examination  of  the  stomach  by  means  of 
a  stomach-tu])e  showed  that  the  organ  would 
hold  about  only  23  ounces  of  water  without  dis- 
tress. Its  lower  border  after  inflation  reached 
just  below  the  navel.  The  contents  extracted 
after  a  test-meal  showed  free  HCl,  o.i  per 
cent.;  no  occult  blood;  no  lactic  acid.  No 
contents  could  be  obtained  from  the  stomach 

,     .         ,         If,  Fig.  ^8. — Chart  of  case    iii. 

before  breakfast. 

Discussion. — There  is  no  need  of  extended  discussion  here.  A 
nodular  mass  in  the  right  iliac  fossa,  accompanied  by  visible  peristalsis, 
marked  constipation,  and  fever,  means  chronic  intestinal  obstruction 
in  the  region  of  the  cecum,  01)struction  at  this  point  is  practically 
never  due  to  fecal  impaction  alone;  there  is  almost  always  some  stricture 
of  the  gut  behind  which  feces  accumulate.  Such  a  stricture  might  bo 
sypliilitic,  cancerous,  or  tu])ercular.  Occasionally  a  chronic  apjK'ndicitis 
with  adhesions  ]iro(luccs  ol)struction. 

Imagine  that  an  a1)scess  lias  occurred  earlier  in  the  hist(^ry  of  tlic 
case;  this  may  later  have  become  walled  ofT  and  niassi'd  into  ;i  tumor 


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somt'tliing  like  that  here  felt.     The  adb.csioiis  associatrd  wlih  it  mi; 
then  lead  to  the  svinntoms  of  obstruction  here  dcscrihfd. 


:ht 


234  DIFFERENTIAL   DIAGNOSIS 

A  retracted  abdomen  and  an  irregular  fever  without  leukocytosis  is 
distinctly  more  suggestive,  however,  of  tuberculosis. 

If  the  stricture  is  tuberculous,  the  tumor  mass  is  probably  made  up  of 
caseating  glands  adherent  to  the  cecum,  itself  infiltrated  by  tuberculosis. 
The  fact  that  the  patient  is  a  negro  and  the  presence  of  fever — especially 
fever  of  the  type  shown  in  this  chart — make  tuberculosis  more  probable 
than  cancer.  Syphilis  rarely  produces  so  large  a  mass  in  this  region. 
Extensive  syphilitic  infiltrations  are  generally  found  near  the  rectum. 
The  diagnosis  of  pericecal  tuberculosis  is  further  supported  by  the 
character  of  the  cutaneous  lesions,  which  are  distinctly  suggestive  of 
tuberculosis. 

No  good  reason  can  be  given  why  the  pain  is  referred  in  this  case  to 
the  right  hypochondrium,  rather  than  to  the  region  of  the  tumor,  as  is 
the  rule  in  such  cases. 

Outcome. — The  patient  rem^ained  ten  days  in  the  ward,  complain- 
ing continually  that  he  did  not  receive  enough  medicine,  but  showing 
no  improvement  in  any  respect.  At  the  end  of  that  time  the  abdomen 
was  opened  and  showed  a  nodular  mass  of  tuberculosis  in  the  cecal 
region,  with  general  adhesions  but  without  fluid.  At  death,  a  month 
later,  tuberculosis  was  found  also  in  the  lungs,  adrenal  glands,  lymph- 
glands,  skin,  and  in  almost  every  other  organ. 

Diagnosis. — Pericecal  tuberculosis. 

Case  112 

A  young  farmer  of  twenty-five,  whose  father  had  died  of  tuberculosis 
but  whose  family  history  was  otherwise  good,  came  to  the  hospital 
January  25,  1906,  with  the  following  story:  For  the  past  fifteen  years 
he  has  had  from  time  to  time  pain  in  the  right  upper  quadrant,  in  attacks 
lasting  from  three  to  five  days,  then  gradually  subsiding  but  leaving 
him  much  used  up.  For  the  past  three  years  the  pain  has  been  so  sharply 
localized  that  it  could  be  covered  with  one  finger. 

Up  to  one  year  ago  he  averaged  about  two  attacks  a  year,  but  within 
the  past  year  the  attacks  have  been  from  one  to  four  weeks  apart,  appar- 
ently depending  upon  the  performance  of  hea\T  work  or  the  eating  of 
hearty  food.  During  these  attacks  the  pain  is  not  constant,  but  comes 
in  spasms  and  is  relieved  by  taking  a  "pain-killer"  and  using  a  hot- 
water  bag,  or  by  leaning  over  the  back  of  a  chair  so  as  to  bring  strong 
pressure  to  bear  upon  the  painful  spot.  In  the  last  attack  the  pain 
radiated  to  the  back,  but  never  to  any  other  point.  Three  years  ago 
he  thought  he  noticed  in  the  region  of  the  pain  a  bunch,  which  was 
tender,    but   gradually   disappeared.     The   painful   spasms   last    from 


RIGHT   HYPOCHONDRIAC   PAIN  235 

fifteen  to  twenty  minutes  each.  He  was  very  sallow  three  years  ago, 
and  thinks  he  has  been  so  since  then.  His  severest  attacks  are  accom- 
panied by  chills  and  fever.  During  the  past  year  he  has  been  able  to  do 
only  very  light  work.  He  occasionally  vomits  during  an  attack,  the 
material  being  usually  greenish.  During  an  attack  he  has  nightly 
emissions.  Walking  on  hard  pavements  or  hard  floors,  especially  dur- 
ing the  time  of  an  attack,  causes  pain  in  the  right  upper  quadrant,  and 
sometimes  shortness  of  breath.  His  appetite  between  attacks  is  always 
good  and  his  bowels  are  usually  constipated.  In  the  fall  of  1905  he 
weighed  185  pounds.  Now  he  weighs  165  pounds.  Work  that  requires 
stooping  or  hea\y  lifting  will  often  bring  on  an  attack  within  two  or . 
three  hours. 

Physical  examination  showed  no  jaundice.  There  was  nothing 
abnormal  in  the  chest  or  abdomen,  and  nothing  wrong  with  the  blood 
or  urine.  After  staying  four  days  in  the  hospital  entirely  free  from 
symptoms  he  was  discharged. 

May  24,  1907,  he  entered  the  hospital  for  the  second  time,  and 
stated  that,  since  leaving  the  wards  fifteen  months  pre\'iously,  he  had 
had  many  attacks  of  ])ain  similar  to  those  previously  described.  His  worst 
attack  was  ten  months  ago,  when  the  pain  failed  to  yield  to  morphin 
or  chloroform,  and  lasted  four  hours.  For  a  week  after  this  he  was 
unable  to  leave  his,bed.  This  spring  he  had  nearly  steady  pain  for  ijye 
or  six  weeks  following  the  ingestion  of  a  large  quantity  of  maple  syrup. 
After  an  attack  his  urine  is  always  high  colored,  almost  black;  the  color 
of  his  stools  is  not  a]:)normal. 

As  on  a  previous  occasion,  physical  examination  was  entirely  nega- 
tive, but  this  time  the  use  of  a  stomach-tube  revealed  that  the  ])ercentage 
of  free  hydrochloric  acid  after  a  test-meal  was  0.29,  and  that  in  the 
fasting  contents  the  percentage  of  hydrochloric  acid  was  0.23.  There 
was  no  reaction  to  guaiac  in  stools  or  gastric  contents. 

Discussion. — There  is  much  to  make  us  think  of  gall-stones  in 
this  case,  though  the  age  and  sex  are  against  this  diagnosis.  The 
association  of  such  a  pain  as  is  here  described  with  chills  and  fever, 
with  deep  discoloration  of  the  urine,  which  may  well  ha^•e  been  due  to 
bile,  and  with  a  bunch  wliich  may  have  been  the  gall-bladder,  gcK'S  far 
to  com|)lete  the  clinical  jMcture  of  cholelithiasis.  This  ])icture  becomes 
still  clearer  as  we  note  the  freedom  from  digestive  s}'m])toms  between 
the  attacks  of  ])ain.  Moreover,  it  mav  be  that  on  stooping  he  shifts 
the  ])ositi()n  of  a  stone  in  the  gall-l)la(lder  in  such  a  way  that  it  ])ec(>mes 
impacted  and  jjroduces  coHc. 

But  this  trouble  has  been  troinu:  on  for  fifteen  vears,  and  i^all-stmies 


236  DIFFERENTIAL  DIAGNOSIS 

are  practically  unknown  in  a  boy  of  ten,  which  was  the  age  of  our  patient 
at  the  beginning  of  his  attacks.  Again,  it  is  difficult  to  see  why  a  gall- 
stone colic  should  not  be  relieved  by  morphin  or  by  chloroform,  and 
why  it  should  not  produce  tenderness  in  the  region  of  the  gall-bladder. 
Patients  who  have  had  many  attacks  of  gall-stones  almost  always  ex- 
perience some  of  the  typical  radiations  of  the  pain,  which,  with  one 
exception,  have  been  wholly  lacking  here.  The  absence  of  jaundice 
and  enlarged  gall-bladder  adds  a  certain  weight  to  the  arguments  already 
adduced  against  gall-stones. 

Next  to  gall-stones,  by  far  the  commonest  cause  of  symptoms  like 
these  is  peptic  ulcer,  gastric  or  duodenal.  The  long  history  of  his 
attacks  and  the  gradually  shortening  intervals  between  them,  the  excess 
of  hydrochloric  acid  in  the  gastric  contents,  and  the  relief  of  pain  by 
pressure  are  facts  tending  to  convince  us  that  peptic  ulcer  is  present. 
On  the  other  hand,  it  is  curious  that  we  were  unable  to  obtain  any 
reaction  to  guaiac  in  the  gastric  contents  or  in  the  stools.  Why  the  pain 
should  be  increased  by  walking  on  hard  pavements  or  hard  floors,  and 
why  the  attacks  should  be  associated  with  nocturnal  emissions,  are 
problems  not  explained  by  any  knowledge  that  I  possess. 

A  "high"  (undescended)  appendix  comes  to  our  minds  as  a  possi- 
bility, but  who  ever  saw  a  case  of  appendicitis — high  or  low — in  which 
the  pain  was  relieved  by  strong  pressure,  as  in  this  case? 

Outcome. — On  May  29th  the  abdomen  was  opened;  a  duodenal 
ulcer  was  found.  It  had  perforated  and  become  adherent  to  the  gall- 
bladder. In  connection  with  the  relief  of  pain  by  pressure  in  this  case 
I  recall  a  case  of  duodenal  ulcer  which  I  saw  with  Professor  Osier  at 
Oxford  in  the  summer  of  1908.  The  man  told  us,  without  a  ghost  of 
a  smile,  that  the  pain  was  so  bad  that  his  wife  often  had  to  kneel  on 
his  stomach  for  half  the  night. 

Diagnosis. — Duodenal  ulcer  (local  peritonitis). 

Case  113 

A  single  woman  of  thirty-seven  entered  the  hospital  on  July  20,  1906. 
Up  to  the  age  of  five  years  she  was  subject  to  convulsions  with  loss 
of  consciousness,  but  these  have  not  recurred  since.  She  had  diph- 
theria with  paralysis  of  the  palate  at  the  age  of  twelve.  In  1892  she 
fell  in  a  gymnasium  and  hurt  her  back,  since  which  time  she  has  done 
no  work,  and  has  suffered  from  severe  pain  in  the  middle  of  the  back 
and  on  the  top  of  her  head.  At  times  she  has  a  sense  of  constriction  in 
her  throat.  She  consulted  an  orthopedic  specialist  in  1902,  and  has 
since  then  worn  a  brace  for  her  back  off  and  on,  with  verv  little  relief.     A 


RIGHT   HYPOCHONDRIAC   PAIN 


237 


spur  was  removed  from  her  nose  one  year  ago.  Three  weeks  ago  she 
began  to  have  very  severe  pain  over  the  right  side  of  the  face,  and  was 
operated  on  for  disease  of  the  antrum,  but  none  was  found.  Her  pain 
was  immediately  reheved,  and  sleep  induced  by  the  subcutaneous  injec- 
tion of  sterile  water. 

Since  that  time  she  has  suffered  especially  from  pain  in  the  right 
hypochondrium — worse  in  the  early  morning,  somewhat  relie\ed  after 
the  morning  urination  or  by  vomiting. 

Physical  examination  shows  rigidity  of  the  abdomen  with  marked 
sensitiveness  of  the  right  half  of  the  head  and  of  the  back,  especially 
in  the  dorsal  region.  The  internal  viscera,  the  blood  and  urine  are 
normal,  likewise  the  temperature  and  pulse.  Respiration  ranges 
between  30  and  45.  She  is  often  awakened  by  spasmodic  pain  in  the 
neck,  much  increased  by  attempts  to  walk.  She  looks  well,  but  still 
complains  "of  soreness  in  the  bowels,  which  prevents  her  from  eating 
and  causes  her  to  vomit  and  her  head  to  ache." 

Discussion. — We  get  a  strong  impression,  on  reading  this  case, 
that  we  are  dealing  with  nervous  invalidism  reinforced  and  made  more 
obstinate  by  a  variety  of  meddlesome  treatments.  But  in  any  case  which 
gives  us  this  first  impression  we  should  do  our  best  to  combat  it  by 
endeavoring  to  establish  the  existence  of  some  form  of  organic  disease. 
Only  in  this  way  can  we  avoid  doing  serious  injustice  to  many  patients 
who  have  both  organic  disease  and  a  rwrvous  make-up,  with  the  latter 
in  the  foreground.  One  of  the  problems  which  first  engaged  our 
attention  was  this:  Why  should  her  pain  be  relieved  after  the  morninci; 
urination?  This  combination  of  symptoms  is  not  at  all  unusual,  and 
in  my  experience  it  signifies  that  the  pain  has  resulted  from  gaseous 
distention  of  the  colon,  which  is  relieved  when  the  emptying  of  the  bladder 
shifts  the  pelvic  tensions  enough  to  allow  the  escape  of  intestinal  gas. 

The  unilateral  distribution  of  sensitiveness  over  the  head  and  trunk, 
the  relief  of  pain  by  the  subcutaneous  injection  of  sterile  water,  the 
rapid  resj)iration,  and  the  history  of  her  medical  fortunes  justify  us,  I 
think,  in  believing  that  our  negative  physical  examination  represents 
the  truth,  and  that  we  are  justified  in  making  that  dangerous  diagnosis; 
hysteria.  But  it  is  only  by  experimental  therapeutics,  that  is,  by  trying 
out  the  results  of  treatment  ))ased  on  the  hyj)othesis  that  we  are  dealing 
with  habit-pain  and  nervous  invalidism,  tliat  we  can  get  aiiy  further 
certainty  u|)on  the  diagnosis.  To  such  experiments,  accordingly,  we 
addressed  ourselves. 

Outcome. — Under  a  combination  of  scolding,  enc<MiragenHut,  ;;nd 
reeducation  she  was  al)le,  at  the  end  of  a  month,  to  walk  lifti'en  yards 


238  DIFFERENTIAL   DIAGNOSIS 

without  support.  Two  weeks  later  she  could  walk  an  eighth  of  a  mile, 
and  the  pain  in  her  head  was  much  relieved.  She  still  complained, 
however,  of  soreness  in  the  bowels,  and  this  she  has  had  at  intervals  ever 
since  that  time,  especially  when  she  gets  run  down. 

This  case  seems  to  me  to  illustrate  well  that  fallacy  about  the  impor- 
tance of  "  reflex  causes  "  for  general  nervous  disturbances  which  had  so 
strong  a  hold  on  the  last  generation  of  medical  men.  The  wonder  is 
that  this  patient  escaped  without  appendectomy  and  hysterectomy.  In 
many  clinics  she  would  also  have  undergone  a  gastro-enterostomy.  I 
think  the  opinion  is  coming  to  prevail  that  when  the  history  and  the 
physical  signs  point  strongly  toward  a  general  neurosis,  attention  to  so- 
called  reflex  or  local  sources  of  irritation  not  only  does  no  good,  but 
makes  the  patient  distinctly  worse  by  concentrating  his  attention  upon 
the  part,  by  increasing  the  period  of  invalidism,  and  by  withdrawing 
him  from  the  normal  supports  and  stimuli  of  the  working  life. 

Diagnosis. — Hysteria  minor. 

Case  114 

A  Portuguese  tailoress,  forty  years  old,  entered  the  hospital  December 
21,  1908.  When  a  little  girl  in  Portugal  she  had  typhoid  fever.  In 
the  preceding  June  she  was  in  bed  for  a  week  with  "malaria,"  and  has 
not  been  well  since.  She  has  now  had  fever  for  five  weeks.  She  has 
been  at  work  for  the  first  two  weeks  of  this  time,  but  has  had  headache, 
anorexia,  vomiting,  diarrhea,  and  cough  for  most  of  the  time  in  the  last 
five  weeks.     She  has  been  in  bed  for  ten  days. 

Physical  examination  shows  no  emaciation.  Many  fine  rales  are 
scattered  over  both  chests,  and  a  few  squeaks  distributed  among  them. 
Whichever  side  she  lies  on  appears  to  contain  the  greatest  number  of 
rales.  There  is  a  slight  cyanosis,  with  mo^'ements  of  the  nostrils  as  she 
breathes.  Voice-sounds  are  slightly  increased  at  the  right  base.  The 
white  cells  are  6800,  56  per  cent,  of  them  being  polynuclear.  Widal 
reaction  positive.     The  spleen  was  palpable  on  full  inspiration. 

On  the  fourth  of  January  she  was  suddenly  seized  in  the  night  with 
sharp  pain  in  the  right  upper  abdominal  quadrant,  accompanied  by 
vomiting,  sweating,  and  a  weak,  rapid  pulse.  Despite  ^  grain  of  mor- 
phin  and  -^^  grain  of  strychnin,  the  pain  and  \-omiting  persisted.  Xext 
morning  there  was  distinct  tenderness  over  the  seat  of  pain,  and  a  tender, 
rounded  mass  was  vaguely  felt  in  the  region  of  the  gall-bladder. 

The  white  cells,  January  5th,  were  12,800  at  10  A.  m.,  23,600  at  9 
p,  M. ;  22,800,  January  6th  at  9  A.  m.  There  was  still  no  abdominal 
si)asm. 


RIGHT   HYPOCHONDRIAC   PAIN 


239 


Discussion. — This  patient  has  a  fever  of  long  duration.  In  tem- 
perate climates,  as  I  have  elsewhere  shown/  there  are  but  three  common 
fevers  which  last  more  than  two  weeks,  viz.,  typhoid,  tuberculosis,  and 
sepsis.  This  woman  has  cough,  cyanosis,  rales  in  both  lungs,  and, 
since  the  nostrils  move  visibly,  she  probably  has  dyspnea.  May  it  not 
be  that  she  has  miliary  tuberculosis  with  tuberculous  peritonitis,  the 
latter  showing  itself  in  one  of  those  acute  paroxysms  which  are  so  often 
mistaken  for  appendicitis,  cholecystitis,  intestinal  obstruction,  and  other 
abdominal  emergencies  ?  But  if  this  is  so,  why  is  the  patient  not  more 
emaciated  after  five  weeks  of  illness?  Unless  we  can  get  evidence  of 
tuberculosis  either  in  the  family  history,  in  the  sputa,  or  in  some  other 
part  of  the  body,  there  is  no  way  of  verifying  this  hypothesis  any  further. 

As  we  read  that  the  Widal  reaction  was  positive,  it  seems  at  first 
unnecessary  to  discuss  the  diagnosis  further.  There  is  nothing  in  the 
case  to  exclude  typhoid,  since  lung  signs  like  those  here  described  may 
represent  simply  the  ordinary  bronchitis  of  typhoid.  But  as  she  has 
previously  passed  through  an  attack  of  typhoid  fever,  it  may  be  that 
her  Widal  reaction  is  one  of  the  residual  results  of  that  illness.  We  know 
that  the  Widal  reaction  may  persist  for  thirty  }'ears  or  more  after  an 
attack  of  typhoid.  The  splenic  enlargement  is  quite  consistent  either 
with  typhoid  or  with  tuberculosis.  As  there  seems  no  good  e\idence  of  a 
generalized  septic  infection,  and  as  the  leukocyte  count  is  at  the  outset  so 
low,  there  seems  no  good  reason  to  consider  any  disease  other  than  typhoid 
and  tuberculosis.  The  rarer  causes  of  prolonged  pyrexia  (meningitis, 
rheumatism,  syphilis,  leukemia,  malignant  disease)  do  not  deserve 
serious  consideration. 

But  there  seem  to  be  two  acts  to  this  drama,  and  the  second — 
which  began  January  4th — throws  consideraljle  light  uj)on  the  first,  for 
the  new  pain  gives  e\'ery  evidence  of  l^eing  due  to  cholecystitis,  and 
cholecystitis  is  a  common  com|)lication  of  typhoid,  not  of  tuberculosis. 

Outcome. — Oj)eration  was  done  on  the  sixth  and  showed  an  injected, 
distended  gall-bladder  filled  with  pus,  ^vith  a  s})ot  of  gangrene  on  the  wall 
and  several  stones  within. 

The  disease  showed  thereafter  the  ordinary  course  of  typhoid. 
Eberth's  bacilli  were  recovered  from  the  gall-bladder. 

Diagnosis. — Cholecystitis  complicating  ty])hoid. 

'R.  C.  r:i1)()t,  Thr  Three  Lonj^-continucd  Fevers  of  New  Knglanci,  Bosi(  n  Med. 
and  Surg.  Jour.,  August  29,  1907. 


240 


DIFFERENTIAL   DIAGNOSIS 


r 

Xray 
findings. 

0 

0 

0 

0              + 

0        0 

+ 

0 

E  S.= 
0  c  ts 
72.5   > 

0 

0 

0 

1.i 

Big  tender  liver. 

Usually  0. 

Sometimes  palpable 

gall-bladder. 

0 

1 

0                0 

T3 

C 

«  E 
9- •J 

r 

> 

_n'3 

•5  « 
0   m 

c  ca 

n 

0 

0 

13 
2 

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V 
T3 

0 

Rest,  depletion, 
and  cardiac 
stimulation. 

Morphin. 

0    . 

.1.2 
0.2 

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.--a 

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*  > 

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rt  0  0. 
0^  S  ° 

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a  S  a 

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0 

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art 
Sa 

.a  0 
< 

J. 3 
'I2 
.a  0 

u 
3    S' 

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H.a 

g^ 
^  0 
< 

Discharge 
of  urina  or 
operation. 

Hgand  KI. 

C    u 

c 

0 

0 

'J  . 

0            °            0      : ll 

1                                    i     3   ^ 

0 

3    2    U 
U    3    U 

a  03 

0 

0 

Often 

other  luetic 

lesions. 

•0 
0 
i2 

0 

c 

s 

0 

t/3 

Relief  by  food.    " 
Recurs  when  stomach 
is  empty. 

0 

0 

0 

0 

0 

0 

0 

0 

0 

c 
3 

1— ^ 

"a 

C 
3 

0                0 

0 

c 

0 

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0 

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0 

0 

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c  0 

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0 

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0 

+ 

+      + 

.2     !  t=   ' 

0    1 

U    3 

ll 

111 

si 

5 

0 

.5  5 

"a 

0 

0 

Usually 
absent. 

In  early 
days  of 
attack. 

Deep  and 
rarely 
severe. 

Slight. 

'rt 

Sharp  and 
constant. 

Comes  at 

regular  intervals 

after  meals. 

Over  kidney  and 
along  ureter. 

•0    . 

2  3 
5:  ■-' 

Not  at  all 
constant. 

Over  ureter. 
U.sually  dull. 

In  early  days 
of  attack. 

Deep  and  rarely 
severe. 

c75 

i  : 

—  t 

"^  3 

_S  K 

Causes. 

Passive  congestion  of 
the  liver 

0 

0 

0 
3 

: 

'J 

1 

■r 

>                   3 

'J 
6         ,       1 

u 

in 

Pneumonia  or  pleural 
inflammation    .    .    . 

Perinephric  abscess    . 

"5. 
3 

>. 

0. 

0 

1     [/ 

CHAPTER   VII 

PAIN  IN  THE  LEFT  HYPCXHONDRIUM 

The  left  hypochondrium  is  not  a  common  place  for  puzzling  pains. 
I  have  known  very  few  diagnostic  problems  which  centered  there. 
Many  discomforts  arising  from  the  stomach  are  felt  in  the  left  hypo- 
chondrium, but,  as  a  rule,  their  origin  and  nature  are  tolerably  clear. 

1.  Flatulence,  the  commonest  of  all  causes  of  pain  in  the  lower  left 
axilla,  is  also  responsible  for  many  complaints  below  the  left  ribs.  The 
relief  by  escape  of  gas  distinguishes  many  such  pains,  but  we  miist 
remember  that  in  many  cases  the  flatulence  itself  requires  explanation. 
Gas-formation  may  be  the  result,  and  its  discharge  the  relief,  of  pain 
due  to: 

(a)  Angina  pectoris. 
{b)  Peptic  ulcer  and  hyperchlorhydria. 
{c)  Chronic  appendicitis. 
(d)  Gall-stones  (rarely). 

Even  toothache  may  cause  recurrent  flatulence  and  be  temporarily 
relieved  each  time  the  gas  (air  ?)  is  discharged. 

2.  Surgical  disease  oj  the  kidney  (stone,  tuberculosis,  neoplasm, 
local  infection,  hydronephrosis)  occasionally  causes  pains  in  the  left 
hypochondrium.  More  often,  however,  the  pain  is  in  the  loin,  in  the 
lumbar  region,  or  along  the  course  of  the  ureter.  The  presence  of  a 
tumor  and  of  urinary  disturbances  usually  makes  it  clear  that  the  kidney 
is  the  source  of  the  pain. 

3.  Adhesions  about  a  spleen  enlarged  by  leukemia,  splenic  anemia, 
malaria,  syphilis,  or  {K)lycythemia  often  produce  pain  in  the  left  hypo- 
chondrium and  above  that  point,  l)ut  the  o])vious  enlargement  of  the 
organ  ])uts  us  on  the  right  track  unless  we  neglect  {)liysical  examination 
altogether. 

4.  Cancer  of  the  S]ilcnlc  flexure  of  the  colon  .rarely  gives  pain  (ncr 
its  own  site.  Usually  such  pains  are  in  the  umbilical  region  or  diUused 
over  the  whole  belly. 

Some  of  the  other  diseases  mentioned  in  Ta1)le  \  may  cause  pain 
in  tlie  k'ft  hypochondrium  as  well  as  in  the  riglit  (c.  ,1;..  itneumc^iiia  an<l 
pleurisy,  es])ecially  in  children),  Ijut  no  separate  discussio!!  of  tluMii  is 
needed  here. 

If.  2\\ 


242  DIFFERENTIAL   DIAGNOSIS 

On  the  whole,  then,  it  appears  to  me  that  most  pains  in  the  left 
hypochondrium  have  either  an  obvious  origin  from  one  of  the  easily 
recognized  sources  mentioned  above  under  i,  2,  3,  and  4,  or  are  to  be 
explained  by  reasoning  identical  with  that  already  applied  to  the 
right  hypochondrium.  Some  of  the  possible  occasions  for  doubt  are 
exemplified  in  the  following  cases: 

Case  115 

A  white-lead  worker  of  twenty-one  entered  the  hospital  July  16, 
1906,  with  negative  family  history,  past  history,  and  habits,  except  that 
he  had  syphilis  four  years  ago.  Five  years  ago  he  passed  some  bloody 
urine,  with  clots,  and  at  times  nearly  pure  blood;  this  lasted  for  about  ten 
days.  He  was  well  after  that  until  two  years  ago,  when  he  began  to  have 
dull,  dragging  pain  wider  the  left  ribs,  fairly  constant  day  and  night  for 
two  weeks,  preventing  work,  but  not  preventing  sleep.  At  this  time 
he  passed  some  "white  stuff"  looking  like  pus  in  his  urine,  mostly  at 
the  end  of  micturition.  After  two  weeks  he  was  well  enough  to  be  about 
and  work,  but  he  still  notices  the  white  stuff  and  occasional  little  strings 
in  his  urine.  At  times  the  urine  is  entirely  clear,  but  for  the  past  five 
months  he  says  it  has  been  clear  for  only  five  consecutive  days.  There 
has  been  no  blood  since  four  or  five  years  ago.  At  times  the  urine  smells 
very  badly.  Eight  months  ago  and  a  year  ago  he  had  similar  attacks  of 
pain,  relieved,  as  formerly,  by  the  passage  of  pus. 

The  present  attack  came  on  five  months  ago;  he  began  to  have  dragging 
pain  under  the  left  ribs,  severe  enough  to  prevent  work,  but  not  sleep. 
At  times  it  doubles  him  up.  At  the  beginning  of  this  period  he  thinks 
he  had  high  fever.  He  now  passes  urine  every  hour.  He  has  lost  nearly 
20  pounds. 

Physical  examination  of  the  chest  is  not  remarkable.  In  the  left 
hypochondrium  is  an  irregular  mass,  palpable  bimanually,  hard,  and 
slightly  tender.     Its  position  is  fixed. 

White  cells,  11,700;  the  temperature  ranges  most  of  the  time  about 
99.5°  F.     There  is  no  elevation  of  pulse  or  respiration. 

The  urine  shows  pus,  at  times  in  large  amounts,  at  times  in  very 
small  amounts.  It  is  not  otherwise  remarkable.  Five  milligrams  of 
tuberculin  were  injected  subcutaneously  and  caused  fever,  constitutional 
symptoms,  and  increased  pain  in  the  tumor. 

Discussion. — If  we  fixed  our  attention  chiefly  upon  the  history  of  this 
case,  our  first  impression  as  to  diagnosis  would  naturally  be  lead-poison- 
ing. Any  abdominal  pain  in  a  lead-worker  may  be  lead  colic.  We  know- 
also  that  lead  affects  the  kidney.     On  the  other  hand,  the  physical  ex- 


PAIN   IN    THE   LEFT    HYPOCHONDRIUM 


243 


animation  includes  data  not  thus  to  be  explained,  and  assures  us  that 
lead  cannot  play  more  than  a  subordinate  part  in  the  case.  The  mass, 
palpable  bimanually,  and  the  pus  in  the  urine  have  nothing  to  do  with 
lead. 

Abdominal  pain  in  patients  who  give  a  history  of  syphilis  should 
lead  us  to  consider  tabes  with  gastric  crises.  As  we  look  over  the  case 
with  this  idea  in  mind,  we  note  that  there  is  no  record  concerning  the 
pupillary  reactions,  the  knee-jerks,  or  the  ankle-jerks.  We  know  that 
tabes  often  leads  to  bladder  troubles,  and  sometimes  to  a  retention  of 
urine.  In  this  way  a  cystitis  and  pyuria  might  have  been  produced, 
and  thence,  by  ascending  infection,  a  pyelonephritis.  In  this  way  all  the 
facts  might  be  accounted  for.  Actually,  howe\;er,  the  pupillary  and 
other  reactions  were  normal,  and  there  was  nothing  to  support  the 
hypothesis  of  tabes. 

Local  renal  disease  giving  rise  to  pyuria  and  tumor,  with  slight  leuko- 
cytosis and  fever,  turns  out  most  often  to  be  due  to  renal  tuberculosis. 
The  positive  reaction  to  tuberculin  is  not  especially  significant  in  an 
adult,  since  many  adults  react  to  tuberculin  whether  they  are  sick  or  well. 
]More  significant,  however,  is  the  increase  of  pain  and  sensitiveness  over 
the  tumor  immediately  following  the  injection.  There  seems  to  be  no 
way  of  obtaining  further  insight  into  the  nature  of  the  trouble  here  pres- 
ent until  we  have  further  information  in  regard  to  the  following  points: 
(a)  Can  tubercle  bacilli  be  demonstrated  in  the  sediment  of  the  centrifu- 
galized  urine?  (b)  If  not,  what  is  the  result  of  injecting  this  sediment 
into  a  rabbit  or  a  guinea-pig?  (c)  What  does  rc-ray  show  in  the  region 
of  the  kidney?  Even  without  these  data,  however,  renal  tuberculosis 
seems  the  most  probable  diagnosis. 

Outcome. — On  July  21st  the  kidney  was  opened  and  a  considerable 
amount  of  pus  evacuated  from  a  trabeculatcd  ca\-ity  in  which  were  frag- 
ments of  stone.     There  was  no  positive  evidence  of  tuberculosis. 

Diagnosis. — Pyonephrosis  with  stone. 

Case  116 

A  car])enter  of  thirty-seven,  whose  mother  died  of  consumption,  had 
an  attack  of  "brain  fever"  eighteen  years  ago,  and  was  in  bed  ten  days. 
Ten  years  ago  he  fell  while  carrying  some  hea\'y  lumber  and  l)r()ke  four 
ribs,  lie  was  laid  up  for  twelve  weeks,  and  his  left  side  "has  never  l>een 
strong  since."  He  has  had  l)lee(ling  piles  for  seven  years.  I  lis  habits 
are  good. 

I'our  years  ago  he  began  to  JKn'e  nrcillc-Ukc  pains  loulcr  iJic  left  cosdil 
mart^in,  coming  on  about  e\ery  fifteen  minutes,  usually  not  si'xx'rr.     ( )c- 


244  DIFFERENTIAL   DIAGNOSIS 

casionally  the  pains  have  been  decidedly  severe,  radiating  to  the  region 
of  the  heart  and  into  the  back.  During  these  attacks  he  usually  sweats, 
and  at  times,  but  not  during  the  attacks  of  pain,  his  heart  seems  to 
pound.  He  has  worked  irregularly,  and  although  at  times  he  felt  faint, 
he  has  never  actually  fainted. 

Twelve  days  ago  he  awoke  in  the  night  with  great  difficulty  in  breath- 
ing, severe  knife-like  pain  about  the  heart,  radiating  to  the  left  arm,  cold 
sweat  upon  the  forehead,  and  great  w^eakness.  The  attack  lasted  five 
minutes.  After  that  he  staid  in  bed  for  a  week  with  slight,  needle-like 
pains  as  before,  and  an  annoying  general  soreness  about  the  heart,  in  the 
left  arm  and  in  the  back.  Four  days  ago  he  awoke  with  a  severe  grasp- 
ing pain  in  the  region  of  the  left  nipple,  extending  through  to  the  back, 
but  not  increased  by  deep  breathing.  He  staid  in  bed  for  the  next  three 
days.  To-day  he  got  up  and  felt  much  better,  but  still  feels  heaviness 
and  soreness  in  the  left  side. 

On  physical  examination  the  heart's  apex  is  seen  and  felt  in  the  fourth 
interspace,  four  inches  to  the  left  of  midsternum.  There  is  no  enlarge- 
ment at  the  right.  The  sounds  are  regular  and  of  good  quality.  A  soft 
systolic  murmur  is  heard  at  the  apex,  transmitted  a  short  distance  into 
the  axilla.  The  artery  wall  is  somewhat  thickened  above  the  elbow,  but 
not  beaded. 

Blood-pressure,  150  mm.  of  mercury  at  entrance;  a  week  later, 
130.     Blood  and  urine  normal. 

In  the  left  lower  back,  below  and  around  the  lower  angle  of  the 
scapula,  over  an  area  the  size  of  the  palm,  breath-  and  voice-sounds  are 
diminished  and  fremitus  is  lessened.  An  area  about  two  inches  in  diam- 
eter in  the  left  midaxillary  line,  over  the  sixth  and  seventh  ribs,  is  tender 
on  pressure.  There  are  scattered  areas  of  tenderness  over  the  ribs  below 
this  point. 

Discussion. — Flatulence  is  the  commonest  cause  of  pain  like  that 
here  described,  but  the  pain  of  flatulence  is  rarely  so  severe,  and  since 
there  are  no  gastric  symptoms  to  speak  of,  we  cannot  account  for  the 
patient's  complaints  in  this  way. 

The  signs  in  the  back  of  the  left  chest  are  consistent  with  a  chronic 
pleural  thickening,  such  as  might  result  from  tuberculosis,  and  the 
family  history  of  that  disease  strengthens  this  possibility.  But  although 
it  is  quite  possible  that  the  patient  has  had  tuberculous  pleurisy,  we  can- 
not account  for  the  paroxysmal  painful  attacks  in  this  way,  especially 
as  they  seem  to  be  independent  of  respiration. 

The  callouses  due  to  broken  ril)s  sometimes  include  nerve  termina- 
tions and  produce  pain  similar  to  that  in  the  stump  of  an  amputated 


PAIN  IN   THE   LEFT  HYPOCHONDRIUM  245 

limb.  Presumably,  we  should  interpret  in  some  such  way  the  patient's 
statement  that  his  left  side  "has  never  been  strong"  since  he  broke  his 
ribs  twelve  years  ago.  But  it  seems  very  unlikely  that  the  recent  parox- 
ysmal attacks  are  due  to  his  broken  ribs.  How  large  a  part  his  old 
pleurisy  may  have  played  in  his  consciousness  of  weakness  in  the  left 
side  and  in  the  heaviness  and  soreness  which  he  still  complains  of  it  is 
difficult  to  say.  The  tenderness  still  complained  of  certainly  cannot  be 
due  to  pleurisy. 

Functional  angina  pectoris  is  the  natural  explanation  for  severe 
precordial  pain  extending  to  the  left  arm  in  a  patient  whose  age  and  rela- 
tively low  blood-pressure  do  not  suggest  organic  disease  of  the  cardio- 
vascular apparatus.  This  idea  is  favored  by  the  long  duration  of  his 
sufferings  and  by  the  fact  that  there  is  no  demonstrable  relation  to 
exertion. 

In  connection  with  paroxysmal  attacks  of  tliis  character,  and  more 
especially  with  precordial  and  left  axillary  pain  of  moderate  severity 
and  long  duration,  the  physician  must  never  forget  the  mental  aspect 
of  the  case.  Pain  supposed  by  the  patient  to  be  in  the  region  of  the  heart 
is  always  made  up  of  two  elements — (a)  The  pain  itself;  and  (/;)  what  he 
thinks  of  it.  The  latter  element  is  all  the  more  imi)ortant  when  it  is  largely 
unconscious.  Dr.  H.  F.  Vickery  tauglit  me  years  ago  that,  in  dealing 
with  patients  who  complain  of  pain  in  the  precordial  or  left  axillary 
region  it  is  always  well,  after  excluding  organic  disease  by  physical 
examination,  to  ask  the  following  question: 

"  Suppose  you  had  that  same  pain  in  your  shin,  would  you  ha\"e  come 
here  to  see  me  to-day?'' 

This  cle\er  little  psychologic  device  of  Dr.  Vickery's  enables  the 
patient  to  separate  the  pain  itself  Jrom  ivhat  he  thinks  of  it,  and  to 
decide  whether  or  not  his  fcir  of  heart  disease  and  its  consequences 
has  added  to  his  sufferings.  To  think  of  the  ])ain  in  his  shin  is  to  think 
of  it  freed  from  the  additions  and  vague  dreads  sure  to  be  associated  w  ith 
j)ain  "around  the  heart."  The  very  vagueness  of  tliese  fears  magnifies 
their  organic  effects,  their  tendency  to  aggra\"ate  pain.  It  is  really  as- 
tounding how  ra])idly  such  a  pain  will  abate  wlicn  the  ])ati(,'nt  under- 
stands that  his  heart  is  entirely  sound. 

Outcome. — On  furtlier  (pieslioning  it  a]>peared  th;;t  the  ])atitnt 
smokes  and  chews  tol)acco  constantly  \\luk>  at  w()rl<.  \\Wr  ten  d^iys  in 
tile  hospital,  during  most  of  whicli  time  the  ]uttient  fi'lt  ]ierlretly  ^\(,•ll, 
he  said  that  he  wanted  to  go  gunnin;:;  aecordinul}"  lie  \\as  achi^-ed  to 
stop  the  use  of  tol)acco  and  discharged. 

Diagnosis. — Functional  angina  pectoris. 


246  DIFFERENTIAL   DIAGNOSIS 

Case  117 

A  laundress  of  forty-five,  with  negative  family  history  and  past  history, 
entered  the  hospital  March  2,  1904.  She  passed  the  menopause  six 
years  ago.  She  has  been  markedly  alcoholic  for  years.  One  month  ago 
she  began  to  ha^•e  pain  in  the  left  hypochondrium,  relieved  by  painting 
with  tincture  of  iodin.  Three  weeks  ago  she  had  a  similar  attack,  re- 
lieved in  the  same  way.  Nine  days  ago  she  had  some  pain  in  the  lower 
abdomen,  relieved  by  a  vaginal  suppository.  Since  then  she  has  been 
in  bed  for  about  half  the  time,  owing  to  nausea  and  pain  in  the  left  hypo- 
chondrium. She  says  she  has  vomited  blood,  but  her  daughter  has  seen 
only  greenish  and  dark-brown  material.  For  a  week  the  urine  has  been 
reddish.     The  patient  has  been  pale  for  about  five  months. 

At  entrance  the  patient  was  apparently  in  a  uremic  condition.  The 
chest  showed  nothing  abnormal.  All  the  superficial  lymph-glands 
were  considerably  enlarged.  Only  a  few  ounces  of  urine  could  be 
drawn  from  the  bladder,  and  this  nearly  clear  blood,  some  pus,  no 
casts.  Blood-pressure,  215.  The  patient  was  semicomatose,  with 
coarse  tremor  of  the  hands.     She  died  on  the  fourth  of  ]\larch. 

Discussion. — Peptic  ulcer  is  naturally  our  first  thought,  but  on 
further  study  of  the  case  there  seems  to  be  little  to  support  it.  The 
condition  of  the  abdomen  and  the  high  blood-pressure  cannot  possibly 
be  thus  explained. 

Cirrhosis  of  the  liver,  with  associated  splenic  enlargement,  might 
explain  the  abdominal  symptoms.  The  vomiting  of  blood  would  then 
be  the  result  of  passive  congestion  of  the  stomach.  The  alcoholic  his- 
tory makes  this  explanation  plausible,  but  on  careful  palpation  we  do 
not  get  the  impression  that  the  abdominal  masses  shown  in  the  diagram 
represent  enlargement  of  the  liver  and  spleen.  There  is  no  sharp  edge 
on  either  side,  and  the  respiratory  mobility  is  slight. 

The  general  enlargement  of  the  superficial  lymph-glands  might  be 
due  to  syphilis.  Enlargement  of  the  spleen  and  liver  is  also  frequently 
the  result  of  this  disease,  and  the  pain  of  which  the  patient  complains 
might  be  due  to  local  peritonitis  (perihepatitis  and  perisplenitis).  The 
gastric  hemorrhage  might  be  explained  under  this  hypothesis  as  a  result 
of  splenic  fibrosis,  the  circulatory  mechanism  being  the  same  as  in 
splenic  anemia.  Against  this,  howe^'er,  may  be  urged  the  same  con- 
siderations which  incline  us  to  rule  out  cirrhosis:  the  abdominal  masses 
do  not  suggest  spleen  and  liver. 

By  the  same  reasoning  and  by  the  negative  results  of  blood  examina- 


V\<i.  ]Sn. — Alxloniiiial  I'lndinj^s  in  Case  117. 


PAIN   IN   THE   LEFT  HYPOCHONDRIUM  247 

tion  we  may  exclude  leukemia,  although  this  disease  would  account  for 
the  glandular  enlargement,  and  (through  a  cerebral  hemorrhage)  might 
explain  the  high  blood-pressure  and  the  semicomatose  condition. 

Tuberculous  peritonitis  as  part  of  a  general  tuberculosis  might  j)roduce 
nearly  all  the  symptoms  of  the  case.  This  disease  produces  masses  more 
or  less  vaguely  felt  in  the  abdomen,  is  often  associated  with  abdominal 
pain,  and,  if  we  suppose  an  accompanying  tuberculous  meningitis  with 
internal  hydrocephalus,  would  explain  the  high  blood-pressure  and  the 
psychic  strte.  We  should  expect,  however,  some  cranial  nerve  paralysis. 
some  fever,  and  some  signs  in  the  lungs,  even  if  only  those  of  diffuse 
bronchitis;  also  some  indication  of  a  focus  whence  the  disease,  previously 
local,  may  have  spread.  Free  fluid  would  probably  be  demonstrable 
in  the  abdomen. 

It  is  not  definitely  stated  in  the  text  that  the  abdominal  masses 
were  palpable  bimanually,  or  that  a  connection  with  the  kidney  was  thus 
suggested.  Whenever  we  have  reason  to  believe  that  some  renal  lesion 
exists,  and  whenever  this  lesion — although  apparently  of  a  gross,  "sur- 
gical" nature— is  associated  with  high  blood-pressure,  we  should  re- 
member the  possibility  of  cystic  kidney.  It  is  rare  to  find  any  other  non- 
nephritic  lesion  of  the  kidney  associated  with  hypertension.  Cystic 
kidney  is  generally  a  bilateral,  congenital  condition.  Why,  then,  should 
these  symptoms  have  appeared  only  within  a  month?  Why  should  the 
disease  have  remained  so  strikingly  latent?  In  answer,  I  can  only  say 
that  this  is  the  usual  course  of  the  disease,  which  encroaches  upon  the 
renal  substance  so  slowly  and  so  gradually  that  the  system  becomes 
accustomed  to  il,  as  to  any  other  form  of  chronic  interstitial  nephritis, 
which  is  practically  equivalent  to  the  condition  here  described.  Just 
what  determines  the  final  breakdown  we  usually  cannot  discover. 

Outcome. — Autopsy  showed  congenital  cystic  kidneys;  there  was 
almost  no  kidney  substance  remaining.  There  was  hemorrhage  into 
several  of  the  cysts  and  pus  in  the  peh'is  of  the  left  kidney. 

Diagnosis. — Congenital  cystic  kidneys. 

Case  118 

A  housewife  of  thirty-nine  lost  one  sister  of  ])hthisis  thirteen  years  ago. 
Family  history  otherwise  good.  In  her  seventeenth  and  in  her  twenty- 
fifth  year  she  was  in  poor  condition  and  was  told  that  sl^c  had  anemia. 
Five  years  ago  she  had  her  first  attack  of  fever,  with  ])ain  in  the  left  low  er 
abdomen.  Since  then  she  has  had  more  or  less  jX'ivic  trouble.  es])ecially 
after  standing  or  after  working  hard.  About  Christmas-time.  1006.  she 
had  frequent  attacks  of  ])ain  in  the  h'ft  upper  ahdomiii;  the  pain  doubled 


248  DIFFERENTIAL   DIAGNOSIS 

her  up,  and  was  ascribed  to  gas  in  the  stomach.  During  the  winter 
the  pain  grew  less,  but  the  abdomen  seemed  to  be  enlarged.  In  March, 
1907,  she  noticed  in  the  left  upper  abdomen  a  visible  prominence,  which 
has  steadily  increased  up  to  the  present  time.  By  May  she  had  to  let 
out  her  clothes  three  inches,  and  thought  she  could  feel  a  lump  in  the  left 
side. 

Now  (June,  1907)  there  is  a  dragging  pain  after  standing,  and  a  feeling 
of  pressure  when  she  lies  on  her  left  side.  Since  early  spring  she  has  had 
frequent  attacks  of  palpitation,  associated  with  pulsation  in  the  neck, 
roaring  in  the  ears,  and  slight  dyspnea.  Once  during  the  summer  she 
saw  red  spots  in  front  of  her  eyes,  but  she  has  noticed  no  bleeding  from 
any  point.  Her  gums  have  several  times  been  swollen.  Three  weeks 
ago,  while  urinating,  she  heard  a  sound  in  the  chamber-pot,  and  looking 
in  saw  that  the  urine  was  very  red  and  contained  several  hard,  dark- 
brown  masses  about  the  size  of  a  large  pin's  head.  She  felt  no  pain  and 
noticed  no  stoppage  of  water. 

When  examined  at  the  hospital,  her  urine  showed  nothing  worthy  of 
note. 

Physical  examination  was  negative  except  as  regards  the  left  hypo- 
chondriac region,  where  she  felt  an  enlargement  (as  figured  in  the  dia- 
gram, Fig.  39).  The  mass  is  only  slightly  tender,  and  moves  freely  with 
respiration;  it  is  very  firm. 

Discussion. — -When  a  patient  tells  us  that  his  stomach  is  so  sore 
that  he  can't  bear  the  weight  of  his  clothes  on  it  and  that  it  is  "all  puffed 
up,"  examination  generally  shows  nothing  in  particular,  no  actual  disten- 
tion or  prominence.  Such  symptoms  usually  occur  in  the  neurotic,  and 
represent  the  referred  pain  described  so  admirably  by  Henry  Head. 
In  the  present  case,  however,  physical  examination  shows  that  the  patient 
is  perfectly  correct  in  supposing  that  the  abdomen  has  enlarged.  In- 
deed, the  results  of  abdominal  palpation  make  it  unnecessary  to  consider 
any  organs  except  the  spleen  and  the  kidney. 

The  present  tumor  seems  to  be  spleen  rather  than  kidney,  for  the 
following  reasons: 

(a)  It  has  a  sharp,  hard  edge,  superficial  and  easily  felt.  Tumors 
of  the  kidney  usually  have  no  distinct  edge,  but  shelve  off  into  the  depths 
of  the  abdomen.  They  are  rarely  as  hard  and  superficial  as  those  con- 
nected with  the  spleen. 

(b)  In  the  present  case  the  tumor  descends  at  least  an  inch  with  full 
inspiration.  Kidney  tumors  sometimes  move  half  an  inch,  often  not 
at  all. 


I'i^-  ,1''-  -I'l-rcussion  outlines  in  a  case  of  lofl-sidcd  ahdoininal  pain. 


PAIN  IN   THE   lEFT   HYPOCHONDRIUM  249 

(c)  One  cannot  grasp  this  tumor  bimanually,  while  bimanual  pal- 
pability is  especially  common  in  renal  tumors. 

{d)  We  are  not  told  whether  or  not  the  air-distended  colon  overlies 
the  tumor,  but  in  view  of  its  superficiality  this  seems  very  unlikely. 
Tumors  overlain  by  the  air-distended  colon  usually  originate  in  the 
kidney  or  retroperitoneal  glands. 

All  the  signs,  therefore,  in  this  case  lead  us  to  believe  that  the  tumor 
is  due  to  the  spleen.  Assuming,  then,  that  this  is  the  case,  we  have  to 
consider  the  following  possibilities: 

{a)  Leukemia  (proved  or  disproved  by  blood  examination). 

{b)  Malaria  (proved  or  disproved  by  blood  examination). 

The  spleen  may  remain  enlarged  long  after  the  malaria  has  died 
out,  a  fact  very  frequently  illustrated  in  Armenian  patients.  In  such 
cases,  however,  the  patient  presents  no  symptoms. 

(c)  Syphilis  (anemia,  hepatic  enlargement,  and  ascites  often  accom- 
pany the  splenic  enlargement) ;  the  history,  the  evidence  of  syphilis 
elsewhere,  the  result  of  treatment  and  of  W^assermann's  test,  must 
decide. 

{(I)  Splenic  anemia  (diagnosis  based  upon  the  presence  of  a  chronic 
anemia,  secondary  in  type,  often  associated  with  gastric  hemorrhages. 
All  other  causes  for  splenic  enlargement  must  be  excluded). 

(c)  Cirrhosis  oj  the  liver  and  Banli  '5  disease.  In  cirrhosis  we  have 
a  hepatogenous  splenic  enlargement;  in  Banti's  disease,  a  splcnogenous 
hepatic  cirrhosis.  The  end-result  is  the  same.  Without  evidence  of 
cirrhosis,  which  is  absent  here,  neither  diagnosis  can  be  made. 

(/)  S[)lenic  enlargement  of  unknown  cause  is  a  rare  but  ^^•cll-recog- 
ni/x'd  clinical  entity.  It  produces  no  symptoms  other  than  those  de- 
pendent upon  the  weight  and  dragging  of  the  enlarged  organ.  The 
diagnosis  rests,  of  course,  upon  the  exclusion  of  all  known  causes, 
such  as  have  ])een  listed  above.  Abscess,  neoplasm,  and  echinococcus 
of  the  spleen  are  so  rare  that,  for  practical  purposes,  they  may  l)e  dis- 
retiardcd.  The  s]>lcnic  enlargements  accompanying  acute  infectious 
disease  never  reach  any  degree  comparable  to  that  shown  in  the  accc^ni- 
panying  diagram  (Fig.  39). 

The  next  step  in  differential  diagnosis  evidently  de])ends  u])on  blood 
examination. 

Blood  examination  sho\\ed  277,000  white  cells;  4,800,000  red  cells; 
75  per  cent.  hemoglol)in.  Among  the  white  cells  were  35  per  cent,  of 
myelocytes;  4  per  cent,  of  eosino])hiles;  2  per  cent,  of  mast  cells;  52  per 
cent,  of  polynuclear  cells. 

Diagnosis. — Myeloid  leukemia. 


2  5© 


DIFFERENTIAL   DIAGNOSIS 


Case  119 

A  girl  of  six  years,  whose  mother"  died  of  quick  consumption,  entered 
the  hospital  September  2,  1907.  She  drinks  three  cups  of  tea  a  day 
and  eats  considerable  candy.  She  was  recently  operated  on  for  con- 
genital cataract  at  the  Eye  and  Ear  Infirmary.  For  nine  days  she 
has  been  suffering  from  weakness,  with  tenderness  and  pain  in  the 
left  upper  quadrant  of  the  abdomen.  September  ist  the  white  cells  were 
19,000.  The  temperature  was  103°  F.  The  Widal  reaction  was  nega- 
tive. There  were  no  parasites  in  the  blood.  The  urine  showed  a 
moderate  amount  of  pus,  but  nothing  else  remarkable. 


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Examined  on  September  2d,  the  child  is  found  to  have  moderate 
photophobia  and  seems  apathetic. 

Examination  of  the  abdomen  is  negative  except  that  in  the  left 
upper  quadrant  there  are  considerable  tenderness  and  slight  spasm 
extending  through  the  left  flank  into  the  back.  There  is  also  dulness 
from  the  seventh  rib  (anterior  axillary  line)  to  the  costal  margin.  The 
patient  is  tender  in  the  costovertebral  angle.  Culture  from  the  urine 
shows  a  strain  of  colon  bacillus,  and  a  hea\y  pus  sediment  which  lasted 
throughout  her  stay  in  the  hospital.  A^-ray  of  both  kidneys  was  normal. 
The  temperature  was  as  shown  in  the  accompanying  chart  (Fig.  40). 


PAIN   IN    THE    LEFT    HYPOCHONDRIUM  25I 

Discussion. — Surgical  disease  of  the  kidney  is  rare  at  this  age. 
Renal  tuberculosis  and  renal  stone,  which  might  account  for  such 
pain,  are  especially  rare  in  small  children. 

The  dulness  in  the  axilla,  the  pain,  fever,  and  tenderness,  might 
be  accounted  for  by  pleurisy.  The  text  does  not  state  whether  or  not 
these  signs  were  supported  by  auscultatory  evidences  of  disease.  We 
should  seek  for  diminution  in  the  respiratory  murmur,  with  decreased 
transmission  of  voice-sounds  and  of  tactile  fremitus.  Friction-sounds 
might  also  be  heard.  As  a  matter  of  fact,  however,  neither  of  these 
confirmatory  signs  was  present,  nor  was  there  any  evidence  of  pneu- 
monia. I  mention  pneumonia  and  pleurisy  especially  l^ecause  in  children 
they  are  frequently  ushered  in  by  abdominal  pain  without  any  reference 
to  the  chest. 

The  most  notable  feature  in  the  physical  examination  is  the  presence 
of  pus  in  the  urine.  Not  many  years  ago  this  might  have  been  passed 
over  with  very  little  attention,  but  since  so  much  has  been  Siiid  and 
written  of  acute  infection  of  the  kidney,  either  hematogenous  or  ascend- 
ing, the  urinary  sediments  are  more  carefully  scrutinized.  We  are 
especially  on  the  alert  in  young  girls  who,  from  babyhood  up,  are  par- 
ticularly apt  to  acquire  renal  infection,  presumably  of  the  ascending  type. 
The  presence  of  the  colon  bacillus  in  pure  culture  in  urine  obtained 
under  aseptic  precautions,  such  as  were  obscr^•ed  in  this  case,  lends 
support  to  the  hypothesis  of  renal  infection.  In  \\cw  of  the  negative 
results  of  .v-ray,  renal  infection  may  ])c  accepted  as  a  working  diagnosis. 
(For  a  discussion  of  clinical  ty])es  of  renal  infection  see  Lumbar  Pain, 
p.  99.) 

Outcome.- — By  the  thirteenth  of  Octol^er  the  patient  was  well. 
The  treatment  consisted  of  counterirritants,  laxati\es,  urotropin,  3 
grains,  three  times  a  day,  and  abundant  water. 

Diagnosis. — Renal  infection. 

Case  120 

A  wool-spinner  of  fortv  entered  the  hos])ital  March  3,  1908.  He  had 
been  in  the  hospital  four  years  before  for  ''gastric  indigestion."  One 
sister  died  of  cancer  of  the  stomach  at  thirty-fne.  He  takes  four  to  six 
cu])s  of  tea  a  day.     His  habits  are  otlicrwise  good. 

Since  the  fall  of  1900  he  has  had  intermittent  pain  iu  the  left  In'fo- 
chondrium,  worse  on  deep  breathing,  associated  with  beicliing,  con- 
siderable nausea  and  vomiting,  loss  of  a])]H'tite,  and  consti]xition.  '1  he 
vomitus  consisted  at  first  of  sour  li(|uid.  later  of  yellow  or  greenisli,  bitter 
liquid  containing  no  pus,  blood,  or  mucus.      Taking    food    sonu'tiiues 


252 


DIFFERENTIAL  DIAGNOSIS 


makes  the  pain  better,  sometimes  worse.  He  has  often  taken  morphin 
to  relieve  the  pain.  For  the  past  two  weeks  he  has  had  the  pain  almost 
constantly.  He  has  done  no  work.  His  best  weight  is  125  pounds. 
Now  he  weighs  117. 

The  patient  is  pale  and  sallow,  with  pigmentation  about  the  eyes. 
His  pupils  are  small,  equal,  and  react  very  slowly,  either  to  light  or 
distance.  The  tonsils  are  somewhat  enlarged.  The  chest  shows 
nothing  abnormal,  nor  docs  the  abdomen.  The  knee-jerks  are  very 
lively.  Water-distention  of  the  stomach  with  a  tube  showed  that  the 
organ  held  28  ounces.  On  inflation,  the  lower  border  reached  about 
one  inch  below  the  navel.  After  a  test-meal  free  hydrochloric  acid  was 
0.32  per  cent.  Lactic-acid  and  the  guaiac  tests  were  negative.  No 
fasting  contents  were  obtained. 

Discussion. — -We  have  here  a  long  period  of  suffering  from  chronic 
dyspepsia,  which  has  led,  as  it  so  frequently  does,  to  the  taking  of 
morphin.  It  is  well  to  remember  this  fact,  since  abdominal  pain  that 
leads  to  a  call  for  morphin  is  often  associated  in  our  minds  with  the 
diagnosis  of  gall-stones. 

Further  analysis  shows  us  that  the  motor  power  of  the  stomach 
is  good  and  its  outlet  free.  There  has  been  no  vomiting  of  food,  but  only 
of  liquid  which  may  be  interpreted  as  gastric  secretion.  Tube  exam- 
ination shows  no  stasis.  Since  most  gastric  cancer  produces  pyloric 
stenosis  and  stasis,  the  absence  of  stasis  in  this  case,  especially  in  \iew  of 
the  long  duration  of  the  symptoms  (1900-1908),  makes  cancer  unlikely. 

Of  leukemia,  pleurisy,  and  the  other  extragastric  causes  for  left 
hypochondriac  pain,  physical  examination  shows  no  evidence.  Cancer 
of  the  splenic  flexure  might  produce  most  of  the  symptoms  here  present, 
but  there  is  no  palpable  tumor  nor  visible  peristalsis,  no  diarrhea,  and  no 
blood  in  the  feces.  The  constipation  here  described  might  be  due  to 
many  causes. 

The  high  percentage  of  hydrochloric  acid  in  the  gastric  contents  is  in 
itself  a  partial  diagnosis,  and  might  account  for  many  of  the  symptoms. 
Our  chief  remaining  proljlem  is  to  determine  whether  anything  more 
serious  than  liyperclilorh}'dria  is  present.  ]\Iany — probably  most — cases 
in  which  hyperchlorhydria  is  associated  with  symptoms  so  long  continued 
and  so  se\'ere  turn  out  sooner  or  later  to  he  peptic  ulcer.  Xo  further 
exactness  of  diagnosis  is  possible  without  operation.  Tlie  absence  of 
the  reaction  to  guaiac,  both  in  the  stomach-contents  and  in  the  feces,  by 
no  means  excludes  ulcer. 

What  treatment  should  ])e  advised  here?  The  jiroper  rule  in  such 
cases  seems  to  me  to  Ije  this:  i!;ive  a  fair  trial  to  treatment  ])v  hvL^icne, 


PAIN   IN   THE    LEFT   HYPOCHONDRIUM 


253 


diet,  and  drugs;  if  these  fail  to  make  the  patient  reasonably  com- 
fortable, advise  operation.  It  does  not  seem  evident,  from  the  data  here 
presented,  that  any  persistent  attempt  has  been  made  to  control  the 
symptoms  by  non-operative  measures.  Such  measures  should,  there- 
fore, be  tried  first.  I  have  had  excellent  success  with  a  modification  of 
Lenhartz's  diet,  suggested  by  Dr.  H.  F.  Hewes,  which  consists  essentially 
of  the  following  regimen: 


For  the  first  two  or  three  days:  For  the  next  two  or  three-weeks: 


2  ounces  of  milk. 
I  powdered  soda-cracker. 
I  ounce  of  sugar. 
To  be  given  every  two  hours 
while  the  patient  is  awake. 


6-8  ounces  of  milk. 
4  powdered  crackers. 
1-2  ounces  of  sugar. 
Eight   such  feedings  in 
twenty-four  hours. 


For  the  final  two  months: 
Milk  and  crackers. 
Indian-meal  mush  with  cream 

or  salt. 
Potato  puree;  jelly. 
Milk  and  whites  of  two  eggs. 
Soft  custard. 
Chocolate. 
Pea  puree. 
Plight  feedings  in  twenty-four 

hours. 


If  the  patient  is  uncomfortable  despite  this  diet,  he  should  take 
cooking-soda  in  doses  sufficient  to  relieve  him.  What  this  dose  is  can  be 
ascertained  only  by  experiment.  It  may  be  anywhere  between  10  grains 
and  2  drams. 

Outcome. — On  a  subsequent  examination  free  hydrochloric  acid 
after  a  test-meal  was  o.ii  per  cent.  The  patient  complained  of  "cold 
sweats"  at  night,  but  under  careful  diet,  small  doses  of  calomel  and 
seidlitz,  olive  oil,  two  teasi)oonfuls  after  meals,  and  an  occasional  lavage, 
he  seemed  practically  well  by  the  eleventh  of  March.  Rest  and  freedom 
from  worry  seemed  to  ha\e  much  to  do  with  his  reco\"ery,  which  b}-  the 
nineteenth  was  complete. 

Diagnosis.— Hy])erchlorhydria. 

Case  121 

A  teamster  of  forty-four  entered  the  hos])ital  A])ril  4,  1908.  He 
has  always  ])een  well  until  four  years  ago,  wlien  he  was  working  on  tlie 
great  Clinton  dam;  a  l)low  in  the  left  side  l)y  a  heavy  ])ile  laid  him  up  for 
six  weeks,  during  wliich  he  suffered  from  ])ain  in  tlie  left  side  and  had 
bloody  urine.  Since  that  time  !ie  has  never  l)een  entirely  free  from  pain 
in  this  region,  and  after  an^•  unusual  exertion  he  has  jiasscd  Mood}-  urine. 
Last  fall  he  ha.d  to  giw  up  work  1)ccause  of  tlie  se\tTity  of  tlic  piiin. 
Three  weeks  ago  he  had  a  S[>eciiilly  sliari)  pa'ni  in  the  l<f/  hv/xh  lioin.'nun'. 
just  below  the  ribs,  the  p;',in  tra\'elin;:  down  the  left  leu.  oc(;i>i<'n;illy 
to  the  left  testis,  and  up  t(n\ard  the  heart.      Since  then  he  has  had  three 


254  DIFFERENTIAL   DIAGNOSIS 

or  four  attacks,  lasting  from  five  to  twenty-four  hours,  all  of  the  same 
character.  When  the  pain  is  severe  he  vomits,  and  is  relieved  to  a  certain 
extent  thereby.  There  is  tenderness  under  the  ribs  in  the  left  hypochon- 
drium  during  and  after  his  attacks.  He  has  been  in  bed  most  of  the  last 
three  weeks,  but  has  passed  no  bloody  urine.  His  weight,  eighteen  months 
ago,  was  197  pounds;  now  it  is  167. 

Physical  examination  shows  nothing  wrong  in  the  chest.  The  arteries 
are  easily  palpable.  The  aortic  second  sound  is  louder  than  the  pulmonic. 
Blood-pressure,  140.  In  the  left  lumbar  region  there  is  slight  volun- 
tary spasm  and  tenderness,  increased  by  ins[)iration. 

The  temperature,  .pulse,  respiration,  and  blood  are  normal. 

The  urine  amounts  to  40  ounces  in  twenty-four  hours;  1022  in 
specific  gravity ;  it  shows  a  trace  of  albumin  and  many  fresh  red  blood- 
cells.     No  casts. 

Discussion. — Can  we  connect  the  symptoms  with  the  injury  sus- 
tained four  years  previously?  The  patient  had  hematuria  immediately 
after  this,  and  he  has  had  it  more  or  less  ever  since.  Can  we  conceive 
any  type  of  trauma  which  would  produce  an  effect  so  lasting?  I  do 
not  see  that  we  can.  The  trauma,  I  think,  must  be  regarded  as  having 
no  important  connection  with  his  present  disease. 

In  the  absence  of  all  bladder  symptoms,  causes  of  hematuria  arising 
there  deserve  no  further  consideration.  The  clinical  picture  is  one  of 
renal  colic  associated  with  hematuria  and  a  loss  of  30  pounds  in  weight. 
Malignant  disease  of  the  kidney  would  produce  these  three  symptoms, 
but  would  hardly  have  lasted  so  long.  Either  it  would  have  killed  the 
patient  or  it  would  have  produced  a  palpable  tumor.  The  hemor- 
rhages from  renal  tumor  are  apt  to  be  longer  continued  and  of  larger 
amount,  leading  to  decided  anemia. 

Tuberculosis  of  the  kidney  of  anything  like  this  duration  would  have 
produced  tumor  and  pyuria.     It  may  be  easily  excluded. 

Chronic  nephritis,  either  of  the  glomerular  or  the  interstitial  type, 
may  be  complicated  by  sudden  attacks  of  hemorrhage  unassociated  with 
any  special  increase  in  the  other  urinary  manifestations  of  disease 
(casts,  cells,  deficient  solids).  Such  hemorrhages  may  be  painless,  or 
may  lead  to  colic,  owing  to  the  formation  of  clots  and  the  difficulty  of 
their  expulsion  into  the  bladder.  The  ])resent  case,  however,  shows  no 
signs  of  nephritis. 

We  have  left  the  two  commonest  and  most  puzzling  occasions  for 
hematuria:  (a)  stone  and  (b)  unknown  cause.  The  latter  is,  I  believe, 
one  of  the  most  frequent  of  all  the  ty])es  of  hematuria.  Between  this 
and  stone  our  chief  means  of  distinction  is  the  .v-rav  examination. 


Fig.  41.— Outlines  bf  mass  referred  to  on  )>.  255.     Palpable  bimanually. 


PAIN  IN  THE   LEFT  HYPOCHONDRIUM 


255 


Outcome. — X-ray  taken  April  8th  showed  a  small  round  shadow  in 
the  region  of  the  left  kidney.  Cystoscopy  helped  to  confirm  the  diag- 
nosis of  stone.     The  stone  was  subsequently  found  at  operation. 

Diagnosis. — Renal  stone. 

Case  122 

A  clerk  of  thirty-five  entered  the  hospital  October  21,  1907.  He 
was  operated  on  for  appendicitis  four  years  ago.  He  had  left-sided 
pleurisy  at  the  same  time.  He  says  he  has  always  been  pale.  Eight 
weeks  ago  he  began  to  have  a  sore,  uneasy  feeling,  first  in  the  left  lower 
quadrant,  later  in  the  left  hypochondrium,  left  hip,  and  over  the  left 
kidney  in  the  back.  He  has  also  had  numbness  in  the  leg,  extending 
from  groin  to  knee.  Three  and  a  half  weeks  ago  he  first  noticed  a 
lump  in  the  left  upper  quadrant,  and  began  at  the  same  time  to  have  a 
very  obstinate  constipation — the  bowels  moving  scantily  by  enema 
only.     No  blood  seen  in  the  stools. 

Examination  showed  pallor  of  the  mucous  membranes  and  negative 
chest,  while  in  the  left  upper  quadrant  there  were  marked  resistance 
and  tenderness.  There  is  also  considerable  tenderness  over  the  anterior 
muscles  of  the  left  thigh.  Four  days  later  palpation  of  the  left  flank 
had  become  easier,  and  a  mass  filling  the  whole  flank  from  back  to 
front,  immobile  and  slightly  tender,  was  easily  felt.  Blood-]:)ressure 
normal.  The  inflated  colon  lay  in  front  of  the  mass.  Urine:  40  ounces 
in  twenty-four  hours;  normal  color;  1020;  no  albumin;  sediment 
negative.     (See  Fig.  41.)     Physical  examination  otherwise  negative. 

Discussion. — Is  it  possible  that  this  patient's  pleurisy  of  four  years 
ago  is  in  any  way  connected  with  his  present  symptoms?  It  is  a  familiar 
fact  that  after  any  [)leurisy  most  patients  ha\'e  a  certain  amount  of 
pain  in  one  or  another  part  of  the  atTccted  side  of  the  chest,  a  pain  that 
lasts  on,  oftentimes,  for  months  and  c^■cn  years.  But  in  such  cases  we 
expect  to  find  some  residual  signs  of  the  old  pleurisy,  and  there  seems 
to  be  nothing  of  the  kind  here.  It  is  obvious,  moreover,  that  pleurisy 
could  not  explain  more  than  a  small  fraction  of  the  facts  in  this  case. 

Leukemia  would  explain  the  lump  and  the  pallor.  I^\cn  in  ad\ance 
of  blood  examination,  ho\\e\er,  leukemia  is  ])raclically  excluded  by 
the  fact  that  the  colon  passes  in  front  of  the  tumor.  The  l)lood  examina- 
tion was  also  ncgati\'e. 

Cancer  of  the  S{)lenic  flexure  of  the  colon  would  ]>ro(luce  a  mass  in 
Just  this  situation,  and  might  account  for  all  the  juiins  hert-  (kscrihcd. 
We  should  ex])ect,  howe\"er,  if  sucli  a  cancer  existrd.  to  get  s(niu-  of 
the  ordinarv  evidences  of  intestinal   obstruction,   such  as  \isil)le   pt-ri- 


256  DIFFERENTIAL   DIAGNOSIS 

stalsis,  intestinal  noise,  gross  or  occult  blood  in  the  stools,  diarrhea,  or 
constipation.  None  of  these  symptoms  was  present  except  the  con- 
stipation, which  may  well  have  been  due  to  other  causes. 

The  tumor  is  in  the  position  usually  occupied  by  growths  arising 
from  the  kidney.  Tuberculosis,  cyst,  and  neoplasm  may  be  considered. 
Against  tuberculosis  is  the  fact  that  we  have  no  fever  and  no  pyuria. 
The  amount  of  pain  and  the  extent  of  its  radiations  exceed  what  we 
usually  find  in  renal  tuberculosis.  The  latter  remark  applies  also  to 
renal  cysts,  which  often  attain  a  much  larger  size  than  the  mass  here 
present  without  producing  any  pain  at  all.  Most  chronic  renal  cysts 
also  produce  an  elevation  of  blood-pressure,  which  did  not  exist  here. 
New-growths  of  the  kidney  might  explain  all  the  symptoms  that  are 
here  present,  but  in  most  cases  would  also  cause  hematuria.  The 
nodular  surface  of  the  growth,  if  the  observation  be  correct,  would 
identify  it  almost  certainly  with  a  neoplasm.  In  some  cases,  how- 
ever, the  irregularities  of  a  cystic  kidney  or  of  a  tuberculous  kidney 
feel  very  much  like  the  nodules  of  malignant  disease. 

Outcome. — The  patient  was  operated  on  March  25th,  and  hyper- 
nephroma found. 

Diagnosis. — Hypernephroma. 

Case  123 

A  single  woman,  thirty-three  years  old,  was  first  seen  June  28, 
1 901.  Family  history,  personal  history,  and  habits  excellent.  Eight 
years  ago  she  weighed  122  pounds;  now,  104. 

For  two  years  she  has  had  almost  daily  attacks  of  severe  general 
bellyache  with  rumblings;  the  pain  is  worse  in  the  left  hypochondrium, 
lasting  one  to  twelve  hours,  doubling  her  up,  making  her  cry  aloud, 
and  radiating  to  the  left  shoulder.  The  pain  has  no  clear  relation  to 
food.  When  the  pain  occurs,  she  usually  vomits,  and  is  promptly  re- 
lieved thereby,  but  in  the  last  seven  months  she  has  vomited  only  twice. 
Vomitus  consists,  as  a  rule,  of  food  eaten  recently,  but  on  se\'eral  occa- 
sions it  has  contained  food  eaten  two  days  before  and  exceeding  the 
amount  of  the  last  meal. 

She  has  distress  and  acid  eructations  one-half  to  one  hour  after 
meals.  Diarrhea  often  comes  with  the  attacks  of  pain  (3  or  4  move- 
ments).    ]Mucus,  but  no  blood,  has  been  seen  in  the  feces. 

She  has  worked  except  during  paroxysms  of  pain. 

Examination. — Well  nourished.  Visible  peristalsis  below  the  navel, 
with    slight   general    fulness   of   the   abdomen.     Much    gurgling.     No 


PAIX    IN    THE   LEFT   HYPOCHONDRIUM  257 

tenderness.     Leukocytes,  8800;  hemoglobin,  95  per  cent.      Borborygmi 
can  be  heard  all  over  the  house. 

Stomach  and  its  contents  negative.  Temperature  (three  weeks) 
normal. 

Discussion. — The  complaint  of  long-standing  gastric  pain  and 
the  evidences  of  gastric  stasis  make  it  reasonable  to  consider  brieOy 
the  possibility  of  hyperchlorhydria  or  of  a  constricting  ulcer  near  the 
pylorus.  jMost  of  the  patient's  complaints  might  be  thus  accounted 
for.  Two  facts,  however,  militate  against  this  diagnosis:  (a)  Peristalsis 
is  visible  below  the  navel.  In  a  well-nourished  patient  this  has  con- 
siderable diagnostic  value,  and  points  to  the  intestines  rather  than  to 
the  stomach  as  the  source  of  trouble,  (b)  Very  loud  intestinal  noise 
is  a  feature  of  the  case.  This,  like  the  peristalsis,  directs  our  attention 
away  from  the  stomach. 

The  record  of  the  physical  examination  is  printed  here  as  it  was 
given  me  by  the  attending  j)hysician.  In  it  we  lack  the  data  necessary 
to  exclude  lead-poisoning  and  taljcs,  either  of  which  might  account  for 
part,  if  not  for  the  whole,  of  the  symptoms.  ]\Iy  own  examination  dis- 
closed no  lead  dotting  of  the  gums,  no  basophilic  stij^pling  of  the  red 
cells,  no  abnormalities  of  the  ocular  or  tendon  rellexes.  The  age  and 
symptoms  are  consistent  with  gastric  neurosis  were  it  not  that  visiljle 
peristalsis  is  revealed  Ijy  examination. 

V/ith  the  exclusion  of  the  possibilities  mentioned  above,  chronic 
intestinal  obstruction  is  left  as  the  most  ]jlausible  diagnosis.  But  what 
is  its  cause?  In  any  ])atient  \\ho  has  had  no  kno\\n  cause  for  the  forma- 
tion of  adhesions  witb.in  the  peritoneal  ca\"ity  ui})pendicitis,  ])yosal]>inx, 
or  gall-bladder  disease,  with  or  without  operation),  cancer  is  the  com- 
monest cause  for  chronic  intestinal  obstruction.  The  age  of  this  ])atient 
does  not  ena])le  us  to  exclude  this  disease.  ^lore  im])ortant  e\idence 
against  cancer  is  the  duration  of  tlie  sym])toms.  Chancer  of  tlie  gut 
often  lasts  two  years  or  more,  l)ut  in  such  cases  it  usually  ])r(Kluces 
a  ])alj)able  tumor.  \n  tlie  absence  of  any  such  tumor  our  best  dir.iinosis 
is:  chronic  intestinal  obstruction  of  unknown  origin;  the  most  signillcant 
sympton^.s  being  the  \isible  peristalsis  and  the  loud  intestinal  noise. 

Outcome. — Operation,  July  i7tli,  showed  sirictures  i  to  (>  inches 
long  in  the  small  gut.  The  gut  was  thickened  and,  in  the  contracted 
])ortions  of  it,  tubercles  could  be  seen. 

Diagnosis. — Tuberculous  enteritis. 


CHAPTER  VIII 

RIGHT  ILIAC  PAIN 

Case  124 

A  (JiRL,  fifteen  years  old,  was  first  seen  July  21,  1898;  six  months 
ago  she  began  to  get  run  down.  Pallor,  dyspnea,  anemia,  and  weak- 
ness brought  her  to  the  out-patient  department,  where,  March  26th,  the 
hemoglobin  was  found  to  be  55  per  cent.  Patient  had  moderate  general 
abdominal  pain  throughout  her  illness,  but  did  not  complain  loudly  of 
it  until  June  21st,  when  it  began  to  be  localized  chiefly  in  the  right  iliac 
region.  It  is  more  soreness  than  pain,  she  says.  Jolting  in  a  wagon 
or  rising  from  a  chair  aggravates  it.  She  limps  in  walking  lately. 
Otherwise  feels  well.  No  fever  (two  weeks'  observation).  Bowels  reg- 
ular.    Last  menstrual  period  ten  days  ago. 

Examination. — Negative  save  for  a  large  hard  "cake"  filling  most 
of  the  right  iliac  region  nearly  to  Poupart's  ligament.  On  the  lower 
side  of  the  mass  is  a  tender  prominence  diagonally  placed.  Leukocytes, 
7400;  hemoglobin,  95  per  cent.  Urine  negative.  Vaginal  examination 
negative. 

Discussion. — The  essential  point  in  this  case  is  the  presence  in 
the  right  iliac  region  of  a  large  mass,  associated  with  anemia  and  pre- 
ceded in  its  development  by  a  considerable  period  of  general  constitu- 
tional symptoms,  such  as  weakness  and  dyspnea.  All  this  in  a  girl  of 
fifteen  can  hardly  be  due  to  the  cause  which  ordinarily  produces  such 
symptoms  in  the  latter  half  of  life — namely,  malignant  disease. 

For  appendicitis  or  pyosalpinx  the  onset  seems  rather  too  gradual, 
the  preceding  constitutional  symptoms  too  marked,  the  fever  and 
leukocyte  count  too  low.  What  was  known  as  to  the  girl's  circum- 
stances seemed  to  render  gonorrheal  infection  very  unlikely. 

Ovarian  tumors,  especially  those  of  the  dermoid  type,  may  occur  in 
girls  of  this  age,  but  rarely  produce  so  much  constitutional  disturb- 
ance, and  are  not  apt  to  be  described  as  a  "cake,"  being,  as  a  rule, 
elastic  and  globular.  The  catamenia  have  been  regular,  the  last  period 
occurring  so  recently  that  extrauterine  pregnancy  seems  impossible. 

Many  points  in  the  case  suggest  pericecal  tuberculosis.  These 
points  arc  especially  the  early  general  weakness  and  anemia,  the  slow 
2r)y 


Causes  of  Right  Iliac  Pain 


1.  APPENDICITIS 

2.  P  U  S-T  U  B  E 

(AND    PELVIC 
ADHESIONS) 


3.  DYSMENORRHilA 

4.  EXTRA-UTER-| 

I  N  E    P  R  E  G-  ' 
NANCY  J 

5.  O  V  A   R    I   A   N^ 

CYST  WITH 
TWISTED 
PEDICLE 

6.  PSYCHONEU- 

ROSIS  AND 
THE  FEAR 
OF  APPEN- 
DICITIS 


7.  COLICA  MUCOSA  I 

8.  URETERAL  i 

STONE       )' 


1169 


427 


31 
23 

21 

17 

5 
4 


Obstn(ctio)i  in  the  ileocecal  retj^ion  {ncoplasui,  tuberculosis,  adlicsioiis^ 
occasionally  produces  right  iliac  {)ain.  As  a  rule,  however,  the  pain 
is  not  thus  localized. 

Iiii^^niiial  hernia  produces  usually  an  ini:^uinal  pain  with  radiations 
which  may  involve  the  iliac  and  other  neic^hborinij;'  reLjions. 

i\ny  of  the  causes  of  s^eneralizetl  abdominal  pain  (<'.  ,C.-  tuberculous 
{)eritonitis)  ma}-  produce  ripj^ht  iliac  pain.  Conversel}',  the  local  causes 
above  mentioned  may  in  exceptional  cases  lead  to  <^'-cnerali/.ed  jxiins. 

Many  of  tlie  drajjjL^ing  "  bearin;^  down  "  iuL^uinal  pains  of  debilitated 
women  (see  pa;^e  8o)  extend  now  and  then  to  one  or  the  other  iliac 
region. 


RIGHT   ILIAC   PAIN  26 1 

onset  and  moderate  degree  of  abdominal  soreness,  the  large  size  of  the 
mass.  Against  this  diagnosis  is  the  absence  of  fever  and  of  any  con- 
siderable disturbance  of  the  bowels.  One  expects  constipation,  with 
or  without  intervals  of  diarrhea.  The  diagnosis  then  lies  between 
ovarian  cyst  and  pericecal  tuberculosis,  inclining  rather  toward  the  latter. 

Outcome. — Operation,  August  4th,  showed  a  tumor  the  size  of  a 
lemon,  studded  with  tubercles — pericecal  abscess  wath  the  tube  also 
involved. 

Diagnosis. — Pericecal  tuberculosis. 

The  two  following  cases  do  not  seem  to  me  to  admit  of  any  accurate 
differential  diagnosis  previous  to  operation.  They  are  introduced  here 
to  suggest  the  variety  of  clinical  pictures  which  pericecal  tuberculosis 
may  present. 

Case  125 

A  little  girl  of  six  was  first  seen  September  19,  1905.  She  had 
whooping-cough  January,  1905.  Since  then  she  has  made  frequent 
complaints  of  pain  in  the  right  iliac  fossa,  worse  after  meals,  and  has 
vomited  almost  every  day.  For  five  months  she  has  had  tenderness 
in  the  painful  region.     No  other  complaint. 

Appetite  good;   bowels  regular;   urine  normal. 

Examinalion. — Poorly  nourished.  Chest  negative.  Belly  ncga- 
ti\e,  save  for  slight  tenderness  in  the  region  of  the  appendix.  Leuko- 
cytes, 8000.     No  fever. 

Operation  as  for  appendicitis.  Tuberculosis  was  found  in  a  loop 
of  small  gut  a])out  four  inches  long.  This  was  excised  and  the  diag- 
nosis confirmed  by  microscope. 

A  year  later  (November  28,  1906)  was  in  "s])lendid  general  condition. 
Api)etitc,  bowels,  and  sleep  satisfactory.  Some  thickening  in  cecal 
region."  "Several  abscesses  have  broken  through,"  and  in  October 
she  entered  the  Children's  Hos|)ital  and  was  very  sick  for  twelve  days. 

Pain  occasionally  wakes  her  at  niglit  (S])asmodic  pain  witli  rumb- 
ling), but  she  soon  drops  aslee]).  She  sometimes  \omits  witli  jus  in — 
once  daily  on  an  a\'erage.  \\'cts  bed  once  or  twice  a  week.  Is  listless 
and  disinclined  to  exertion.  No  dyspnea.  \\'eiglit,  31  jxuinds.  Slight 
resistance  in  a])pendix  region.     No  spasm;   no  tenderness. 

Diagnosis. — Pericecal  tuberculosis. 

Case  126 

A  young  Assvrian  was  admitted  March  k).  I()o6,  for  chr(inic  appen- 
dieilis.     Se\eral  attacks  of  riirht  iliac  iviin  in  tlie  oast  vt'iir.      J)iarr!iea 


262  DIFFERENTIAL   DIAGNOSIS 

with  one  attack.  Nd  vomiting.  Most  of  the  attacks  last  a  few  hours 
only.     Bowels  regular. 

Examination. — Chest  negative.  Belly  negative  except  for  a  large 
mass  indefinitely  outlined  in  the  right  iliac  region,  with  slight  tenderness 
and  spasm. 

Mass  was  not  affected  by  free  catharsis.  Comfortable.  No  fever. 
Pulse,  90. 

Operation  March  21st:  Some  free  fluid.  A  nodular  mass  in  the  ileo- 
cecal region.  Similar  smaller  masses  could  be  felt  in  the  mesentery  and 
along  the  cecum.     Cecum  adherent. 

April  14th  discharged  v.ell. 

Microscopic  examination  of  excised  piece  showed  tuberculosis. 

Diagnosis. — Tuberculosis  of  the  cecal  region. 

Case  127 

Consulted  October  23,  1902,  by  a  married  woman  of  thirty-one 
Viho  has  had  left  tube  and  ovary  removed  at  Boston  City  Hospital  in 
1897.  For  eighteen  months  she  has  been  more  or  less  constantly  in 
pain,  referred  to  the  right  lower  quadrant.  For  the  past  six  weeks  it 
has  been  severe.  No  fever  or  chills.  Last  menses  in  July,  and  again 
three  weeks  before  entrance,  when  she  flowed  for  five  days,  using  fi\'e 
napkins  a  day.     Many  clots  came  away,  one  the  size  of  a  hen's  egg. 

The  diagnosis  of  the  attending  physician  is  extrauterine  pregnancy. 

Examination. — Tenderness  over  the  uterus  and  in  appendix  region. 
Movable  pelvic  mass  on  the  right,  thought  to  be  closely  attached  to  the 
uterus,  which  does  not  seem  enlarged. 

The  patient  ran  a  slightly  elevated  temperature  with  a  normal  pulse. 
Her  general  condition  n'as  excellent.     Twelve  days'  observation. 

Discussion. — -The  essentials  in  this  case  are  right  iliac  pain  of 
eighteen  months'  duration  and  amenorrhea  of  three  months.  The 
latter  fact  strongly  inclines  us  to  believe  that  the  genital  tract  is  in- 
volved, and  tends  to  exclude  a  simple  appendicitis.  Amenorrhea  is 
consistent  with  any  of  the  following  possibilities:  Normal  pregnancy, 
extrauterine  pregnancy,  pyosalpinx,  ovarian  cyst,^  fibroid  tum.or,  peri- 
tubal tuberculosis.  It  is,  however,  less  frequent  in  ovarian  cysts  and 
in  pyosalpinx,  and  very  much  less  frequent  when  fibroid  tumors  are 
present  than  in  either  form  of   pregnancy.      The  flow  which    is   said 

^  I  shall  make  no  attempt  in  this  or  in  subsequent  cases  to  distinguish  between  ovarian 
and  parovarian  cysts,  nor  Ix'tween  either  of  these  and  a  cyst  of  the  broad  lig-rnent  or  a 
hydrrsalpinx.  I  do  not  believe  that  these  can  often  be  distinguished  by  physical  ex- 
amination alone. 


RIGHT    ILIAC    PAIN 


263 


to  have  occurred  three  weeks  before  entrance,  came  at  a  time  not  cor- 
responding to  the  menstrual  period.  In  many  ways  it  sounds  like  a 
miscarriage,  but  one  must  be  on  one's  guard  when  patients  give  a 
history  such  as  this,  for  not  infrequently  stories  of  pure  fabrication  are 
designed  to  induce  the  physician  to  curet  the  uterus  and  thereby  to 
bring  about  a  miscarriage. 

Very  possibly  the  diagnosis  might  have  been  made  clearer  had  a 
uterine  sound  been  introduced,  but  in  view  of  the  possibility  of  pregnancy 
this  was  obviously  improper.  On  the  whole,  the  diagnosis  seems  to  me 
to  be  impossible,  and  the  case  is  introduced  merely  as  an  example  of 
the  present  limitations  of  our  diagnostic  skill. 

Outcome. — Operation  for  ovarian  cyst  revealed  normal  pregnant 
uterus  (three  months)  strongly  right  latero-vertcd.  Subsequently 
tried  to  miscarry  at  six  months  but  failed,  and  child  v.'as  born  at 
term  (Boston  Lying-in  Hospital). 

Diagnosis. — Normal  pregnancy. 

Case  128 

A  married  woman  of  forty-two;  has  one  child  two  years  old,  and 
suffered  a  miscarriage  three  years  ago. 

For  three  months  has  had  periodic  attacks  of  pain  in  the  right 
lower  abdomen  which  make  her  feel  ''sick  all  over."  These  came  at 
first  every  four  weeks,  now  every  two  weeks.  Vomiting,  constipation, 
distention,  relieved  by  enemata.     Catamenia  normal. 

Last  attack  began  ten  days  ago,  and  pain  has  persisted  since.  It 
shoots  into  right  hip  and  flank.  When  she  reaches  out  for  anything 
she  has  a  sense  of  tension  in  the  right  lower  belly. 

Exammation. — Hard,  smooth  tumor  in  right  iliac  region,  fairly 
tender,  about  size  of  a  large  orange.  No  fluctuation.  \'aginal  examina- 
tion cannot  determine  whether  or  not  tumor  is  connected  with  uterus. 
No  fever.     Leukocytes  normal. 

Discussion. — We  rightly  consider  ay)pendicitis  in  e\ery  patient 
who  complains  of  right  iliac  j)ain,  but  in  the  present  case  this  possibility 
may  be  promptly  dismissed.  An  appendix  abscess  rarely  if  exer  lasts 
so  long  or  attains  such  a  size  as  this  without  {)roducing  more  con- 
stitutional and  local  disturbance. 

Tubal  abscess  would  probably  ])roduce  more  tenderness,  and  rarely 
attains  this  size.  The  woman's  age  is  not  typical  for  tubal  disease,  though 
tiiis,  in  itself,  is  not  a  point  of  great  importance. 

The  tumor  suggests  especially  uterine  fibroid  and  oxarian  cyst. 
Fibroids  are  more  apt  to  be  situated  in  the  median  line  and  to  be  ob\i- 


264  DIFFERENTIAL  DIAGNOSIS 

ously  connected  with  the  uterus.  They  are  rarely  smooth.  Unless  they 
lead  to  profuse  flowing,  they  usually  cause  no  symptoms  of  any  impor- 
tance until  a  considerably  greater  size  has  been  reached. 

Except  for  its  extreme  hardness  and  the  absence  of  mobility,  the 
tumor  is  fairly  typical  of  ovarian  cyst.  Cysts  of  this  size  rarely  produce 
marked  symptoms  unless  the  pedicle  becomes  twisted,  with  resulting 
necrosis,  hemorrhage,  or  local  peritonitis.  Any  of  these  conditions  may 
be  here  present. 

Outcome. — Operation  showed  a  cyst  the  size  of  a  child's  head. 
Its  pedicle  was  twisted.  The  patient  was  discharged  in  three  weeks. 
A  year  later  she  was  heard  from  and  had  remained  entirely  well  since 
her  operation. 

Diagnosis. — Ovarian  cyst  with  twisted  pedicle. 

Case  129 

An  Italian  laborer  of  twenty-four  entered  the  hospital  August  22, 
1908,  complaining  of  right  iliac  pain  which  has  been  severe  only  for 
ten  days,  but  had  troubled  him  off  and  on  since  March.  He  has  had 
no  constipation,  vomiting,  jaundice,  or  headache. 

The  pain  is  worse  at  night,  is  somewhat  relieved  by  applications 
of  iodin,  and  somewhat  increased  by  the  taking  of  food. 

Worked  until  four  days  ago.     Family  and  previous  history  good. 

Examination. — Scars  in  the  neck  near  the  angle  of  the  jaw.  Tender- 
ness throughout  the  belly  on  deep  pressure,  most  marked  in  the  right 
iliac  region.  Physical  examination,  including  the  blood  and  urine,  tem- 
perature, pulse,  and  respiration,  showed  nothing  else  that  was  abnormal. 

Discussion. — This  case  was  operated  upon  as  one  of  acute  appendi- 
citis. Against  this  diagnosis,  however,  were  urged  the  following  con- 
siderations, to  which,  as  I  think,  insufficient  attention  was  paid.  The 
patient's  pain  was  never  sharp  and  never  well  localized.  The  same  was 
true  of  his  tenderness.  He  ne\'er  suffered  from  constipation,  ^■omiting, 
or  fe\'er;  his  blood  showed  no  leukocytosis.  In  view  of  these  facts  it 
seems  to  me  that  all  the  other  possibilities  should  have  been  considered. 

His  symptoms  have  been  of  long  standing  and  ha^■e  increased  little 
in  se\'erity.  The  long  history  of  the  case,  the  scars  in  the  neck,  and  the 
fact  that  the  patient  is  a  recently  arrived  Italian  immigrant,  make  ab- 
dominal tuberculosis  a  genuine  possi])ility.  Many  cases  of  al)dominal 
tu]:)erculosis  produce  no  more  symptoms  than  arc  here  described,  al- 
though the  absence  of  fever  is  somewhat  surprising. 

The  pain  has  none  of  the  radiations  characteristic  of  stone  in  the 
ureter,  and  there  has  been  nothing  in  the  urine  to  suggest  this  disease. 


RIGHT  ILIAC   PAIN  265 

Gall-stone  pain  is  sometimes  referred  to  the  right  iliac  region,  but  no 
diagnosis  of  gall-stone  disease  is  possible  upon  the  evidence  here  pre- 
sented. There  seems  no  good  reason  to  suspect  any  part  of  the  gastro- 
intestinal tract. 

Young  Italian  laborers  rarely  suffer  from  functional  neuroses.  I  have 
once  known  a  case  somewhat  similar  to  this  in  which  the  patient  turned 
out  to  be  a  malingerer,  but  he  had  obvious  reasons  for  his  lies,  while  this 
patient  has  none.  On  the  whole,  I  think  that,  had  tuberculosis  been 
seriously  considered  by  the  surgeon  who  performed  the  operation,  the 
diagnosis  of  appendicitis  would  never  have  been  made. 

Outcome. — Operation  revealed  a  normal  appendix.  Many  glands 
of  the  size  of  marbles  were  felt  in  the  mesentery  and  along  the  spinal 
column.  Two  of  them  seemed  a  little  soft  on  one  side.  The  patient 
made  a  rapid  and  permanent  recovery. 

The  outcome  of  this  case  seems  to  me  to  prove  that  the  glands  were 
tuberculous.  The  patient's  recovery  proves  that  they  were  not  malig- 
nant, and  there  is  nothing  to  make  us  suspect  typhoid.  What  should 
have  been  the  treatment  had  the  diagnosis  been  known  before  operation? 
Clearly,  I  think,  it  should  have  been  purely  a  hygienic  and  dietetic 
one,  similar  to  that  applied  in  pulmonary  tuberculosis. 

Diagnosis. — Tabes  mesenterica. 

Case  130 

A  young  married  woman  complains  that  since  her  second  child  was 
bom,  four  months  ago,  she  has  had  intermittent  right  iliac  pain  in  spells 
of  one  to  two  weeks.     It  is  worse  on  standing  or  (exertion. 

Examination. — Slight  enlargement  of  the  thyroid.  Flat,  globular, 
smooth  mass,  the  size  of  a  grape-fruit,  is  felt  in  right  iliac  region.  Jt 
can  be  mo^•ed  to  the  other  side  of  pelvis.  Distinct  fluctuation  waxe  o\"er 
it.     No  connection  with  uterus  can  be  made  out. 

Next  day  (September  15th),  at  4  p.  m.,  sudden  right  iliac  agony  with 
vomiting.  It  lasted  until  12  P.  M.  Then  she  slept  (no  drug).  Free  fluid 
was  demonstrated  in  the  peritoneal  ca\"ity. 

September  i6t]i,  comfortable  in  day — similar  attack  in  evening. 

Se[)tember  lyth:  Operation:  Ovarian  cyst  with  twisted  pedicle  (free 
l)loody  fluid — as  iisual). 

Discussion. — This  is  a  ty])ical  case,  quite  easy  of  diagnosis.  The 
smooth,  globular,  painful  mass  in  the  right  iliac  region,  the  free  mobility 
of  the  tumor,  the  sudden  advent  of  agonizing  ])ain.  and  tbc  cxidcuccs 
of  free  fluid  in  tlic  perit(>neal  ca^■ity  make  up  the  ty]>ical  ])icturc  of  (>\arian 
cyst  with  twisted  ])edicle.     In  n:;iny,  perliaps  most,  cases.  lioweMT,  we 


266  DIFFERENTIAL   DIAGNOSIS 

cannot  be  so  sure  either  of  the  cyst  or  of  the  twist  because  we  have  had 
no  opportunity  to  question  and  examine  the  patient  previous  to  the  advent 
of  any  acute  symptoms.  Very  large,  centrally  placed  cysts  are  recog- 
nizable in  case  they  project  sharply  forward,  leaving  the  flanks  compara- 
tively free  from  bulging  and  still  resonant  on  percussion.  The  diag- 
nosis is  much  aided  if  the  patient  has  been  able  to  notice  that  the  tumor 
originated  at  one  side  of  the  abdomen  and  only  assumed  its  central 
position  at  a  later  date.  But  the  majority  of  patients  remember  nothing 
of  the  kind  and  pay  no  special  attention  to  their  condition  until  it  gradu- 
ally dawns  upon  them  that  the  enlargement  cannot  be  due  either  to 
fat  or  to  the  so-called  "high  stomach."  Under  these  conditions  it  may 
be  difficult  or  im])ossible  to  distinguish  the  disease  from  tuberculous 
peritonitis.  The  other  and  commoner  causes  of  ascites  (cirrhosis,  cardiac 
or  renal  disease,  cancerous  peritonitis)  are  more  easily  recognized. 

In  another  group  of  cases  the  cyst  is  smaller  and  bears  no  great  re- 
semblance to  an  ascitic  accumulation,  but  is  of  such  a  board-like 
hardness  that  we  can  scarcely  imagine  its  contents  to  be  fluid.  A  careful 
examination  under  ether  and  the  introduction  of  a  uterine  sound  will 
usually  determine  the  point. 

As  a  rule,  it  is  useless  to  attempt  any  distinction  of  the  different 
varieties  of  ovarian  tumor.  Occasionally  the  smaller  and  more  solid 
tumors  (ovarian  fibroid,  cancer,  or  sarcoma)  may  be  recognized  by  their 
consistency,  and  especially  by  their  association  with  ascites,  which  is 
much  commoner  with  solid  than  with  cystic  tumors. 

The  occurrence  of  a  twist  in  the  pedicle  of  an  ovarian  tumor  is  often 
recognized  without  difficulty,  pro\ided  we  have  seen  and  studied  the  case 
before  the  twist  occurred.  If  we  know  that  an  ovarian  tumor  is  present, 
the  occurrence  of  any  kind  of  acute  abdominal  symptom  is  strongly  sug- 
gestive of  a  twist.  But  if  we  see  the  patient  for  the  first  time  after  the  acute 
symptoms  have  appeared,  it  may  be  quite  impossible  to  make  out  any- 
thing which  enables  us  to  distinguish  the  condition  from  perforative 
peritonitis  or  intestinal  obstruction.  The  abdomen  may  be  so  tender  and 
its  muscles  so  spastic  that  nothing  definite  is  distinguished  on  physical 
examination,  while  the  pain,  vomiting,  constipation,  and  general  pros- 
tration are  quite  equivocal. 

Diagnosis. — Ovarian  cyst  with  twisted  pedicle. 

Case  131 

A  seventeen-year-old  school-girl  has  had  three  attacks  like  the  present 
one,  the  last  eight  months  ago.     Catamenia  regular  and  normal. 


RIGHT  ILIAC   PAIN  267 

Yesterday  general  abdominal  pain,  with  vomiting  and  diarrhea, 
brought  her  to  her  physician. 

Examination. — Temperature,  102°  F.;  pulse,  105;  respiration,  25. 
Slight  rigidity  and  considerable  tenderness  in  right  iliac  region.  Leuko- 
cytes, 14,000.  Operation:  Normal  appendix.  Considerable  bloody 
fluid  in  pelvis.  Ruptured  ovarian  cyst  one  inch  in  diameter,  whence 
oozed  gelatinous  material. 

Discussion. — ]Much  that  was  said  in  the  discussion  of  the  last  case 
applies  equally  to  this  one.  With  no  accurate  knowledge  of  her  condi- 
tion pre\ious  to  the  present  attack,  appendicitis  was  the  most  natural 
and  reasonable  diagnosis.  Such  mistakes  cannot  be  avoided.  It  is  on 
this  account  that  I  have  not  discussed  ruptured  ovarian  cyst  in  detail 
among  the  possibilities  to  be  considered  in  difTcrential  diagnosis,  as  I 
ha\e  intended  to  deal  chiefly  with  the  recognizable  and  verifiable  possi- 
bilities. 

Diagnosis. — Ruptured  ovarian  cyst. 

Case  132 

A  married  woman  of  forty-seven  was  seen  January  25,  1908.  Eight 
months  ago,  on  getting  out  of  bed,  she  felt  sudden  sharp  right  iHac 
pain,  which  ceased  in  one  hour  on  lying  down.  Many  attacks  since — - 
lately,  three  or  more  every  week. 

Two  months  ago  noticed  a  lump  in  right  side  of  belly.  Thought 
she  was  getting  fatter  there;  lump  seemed  larger  during  the  attacks  of 
pain.     Thinks  she  has  lost  weight  in  the  rest  of  her  Ijody. 

Examination. — Thin,  worn  face.  Belly  prominent,  es]:)ecially  to  the 
right  of  the  median  line  below  the  navel.  Dull  here,  tym])any  elsewhere. 
A  large,  slightly  compressible  mass,  extending  from  the  pelvis  to  a  hand's 
breadth  above  the  navel.  Not  tender;  freely  movable.  \'aginal  ex- 
amination adds  nothing. 

0|)eration  revealed  a  multilocular  ovarian  cyst  about  24  cm.  in  diam- 
eter. There  were  no  adhesions  except  a  few  about  the  a])pendix. 
Well  in  two  weeks. 

Discussion. — This  case  is  introduced  to  exemplify  the  occurrence 
of  attacks  of  pain  in  connection  with  an  ovarian  cyst  easily  recognizable 
as  such.  These  attacks,  howe\'er,  were  demonstraljly  not  due  to  a 
twisting  of  the  ])edicle.     Tlieir  cause  is  not  explained. 

Diagnosis. — Ovarian  cyst. 


268  DIFFERENTIAL  DIAGNOSIS 


Case  133 


A  man  of  forty-eight  has  had  for  two  days  pain  in  right  side  of  belly, 
extending  to  the  back,  tending  to  shoot  upward,  and  increased  by  motion. 
Dull  ache  with  exacerbations.     No  other  symptoms. 

Temperature,  ioo°  F.;  pulse,  62.     Leukocytes,  12,000. 

Tenderness  in  right  loin  and  along  the  ureter  down  to  McBurney's 
point.     No  muscular  spasm.     Urine  normal. 

The  tenderest  areas  are:  (a)  Midway  between  the  ribs  and  the  ante- 
rior superior  iliac  spine;  (b)  over  the  right  kidney. 

Discussion. — Although  this  case  was  diagnosed  and  operated  upon 
as  appendicitis,  there  are  several  points  distinctly  against  that  diagnosis. 
In  the  first  place,  it  is  important  that  the  pain — and  especially  the  tender- 
ness— centered  rather  in  the  loin  and  over  the  ureter  than  at  McBurney's 
point.  The  absence  of  muscular  spasm  is  also  distinctly  against  appen- 
dicitis. Dull  aching  pain  w^ith  exacerbations  occurs  in  appendicular 
colic,  but  also  in  colic  of  other  origin  (intestinal,  biliary,  renal,  uterine). 

So  much  in  this  case  suggests  kidney  that,  even  though  the  urine  is 
normal,  cystoscopy  and  the  introduction  of  a  catheter  into  the  ureters 
seems  indicated. 

Outcome. — Operation  showed  in  the  ureter  a  stone  the  size  of  a 
large  bean.     Recovery  was  uneventful. 

Diagnosis. — Stone  in  the  right  ureter. 

Case  134 

A  factory  girl  of  twenty-four  entered  the  hospital  June  21,  1906. 
She  had  pleurisy  eighteen  months  ago.  One  month  ago,  without  known 
cause,  her  abdomen  began  to  be  sore  and  tender  on  pressure,  especially 
in  the  lower  portion  and  on  the  right  side.  There  has  been  no  actual 
]jain,  but  she  has  been  too  weak  to  work,  and  has  been  part  of  the  time  in 
bed.     The  menses  have  been  regular  and  normal. 

Physical  examination  showed  normal  temperature,  pulse,  and  res- 
piration, nothing  abnormal  in  the  chest,  general  rigidity  of  the  abdomen, 
especially  in  the  right  lower  quadrant,  where  there  are  marked  tender- 
ness and  an  oval  mass,  the  size  of  half  a  lemon,  raised  above  the  surface. 

Discussion.— The  presence  of  a  raised  mass  in  the  region  of  the 
appendix  narrows  the  field  of  possibilities  considerably.  The  most 
important  differential  point  in  the  case  seems  to  me  to  l)e  the  gradual 
onset  of  the  symptoms  and  signs,  without  anything  that  the  girl  will  call 
pain.  Appendicitis  and  pyosalpinx  may  have  a  gradual  onset,  l)ut  almost 
never  does  this  occur  without  marked  jjain.     If  these  two  possibilities 


RIGHT   ILIAC   PAIN  269 

are  for  the  moment  put  on  one  side,  we  have  left  ovarian  cyst,  cancer, 
and  tuberculosis  of  the  cecal  region  and  extrauterine  pregnancy.  If 
we  believe  the  girl's  story,  the  latter  is  excluded  by  the  regularity  of  men- 
struation and  the  absence  of  pain.  Cancer  is  very  rare  at  her  age,  and 
should  produce  symptoms  more  distinctly  referable  to  the  intestine. 
0\'arian  cyst  cannot  be  excluded,  but  there  are  two  points  which  in- 
cline us  to  the  only  remaining  alternative,  tuberculosis.  These  points 
are:  (a)  the  occurrence  of  a  pleurisy  (/.  e.,  of  a  tuberculosis)  eighteen 
months  previously;  and  (b)  the  wide  distribution  of  tenderness  and 
rigidity  over  the  aljdomen.  Ovarian  cysts  generally  cause  \ery  little 
either  of  tenderness  or  of  muscular  spasm,  except  in  the  presence  of  other 
acute  symptoms,  such  as  are  absent  here. 

Outcome. — The  patient  was  operated  on  June  23d.  A  large  tuber- 
cular al)sccss  originating  in  the  right  tube  was  drained. 

Diagnosis. — Tul^erculosis  of  rigiit  tube. 

Case  135 

A  married  woman  of  thirty-nine  entered  the  hospital  July  29,  1908. 
Her  father  died  of  consumption;  one  of  her  sisters  is  partially  paralyzed. 
The  patient  was  a  seven-months'  baby,  and  was  said  to  ha\e  weighed 
only  a  pound  at  birth(? ;.  She  has  had  measles  four  times,  and  many  at- 
tacks of  grip.  A  year  ago  she  had  an  attack  similar  to  the  ])resent  one. 
She  formerly  took  alcohol  in  considerable  (|uantities  "to  gi\"e  her 
strength,"  and  for  six  montlis  she  has  not  felt  well  and  has  had  darting 
pains  in  various  parts  of  the  abdomen,  especially  in  the  right  iliac  region, 
also  in  the  back,  knees,  and  other  joints.  Three  days  ago  she  ])egan 
to  have  frecjuent  loose,  slimy  mo\ements,  with  much  j)ain  in  tlie  riglit 
iliac  region.     The  ])ains  in  the  joints  and  l)ack  have  also  been  increased. 

Physical  examination  shows  a  slight  systolic  thrill  at  the  a])ex  of  the 
heart,  with  a  systoHc  murmur,  which,  liowever,  is  loudei  in  the  ])i'Im()nary 
area,  and  not  heard  in  the  axilla.  There  is  no  enlargement;  sHglU  gciUTal 
abdominal  tenderness,  more  marked  in  the  right  iH;;c  region;  blood, 
urine,  pulse,  tem])erature,  and  res])iration  are  normal.  Tlie  stools  sh()\\ 
a  few  food  elements  and  large  amounts  of  mucus.  The  patient  lies  in 
bed  with  her  eves  closed  most  of  the  time,  ]xiying  no  attention  to  what 
is  going  on  about  her,  but  complaining  of  pains  in  dilferen.t  ]iarts  of  her 
bodv. 

Discussion. — The  susj)ieion  of  tuberculosis  which  is  naturally  ex- 
cited when  we  learn  that  tlie  ])atienfs  father  died  oi  i:onsuini>tion 
recei\'es  \'er\'  slight  support  from  anv  of  the  otlu'r  fatis  in  the  c;i>e.  It 
is  true  that  the  patient  has  slight  gt-neral  alxloniinal  teinlcrnos.  but  at 


270  DIFFERENTIAL   DIAGNOSIS 

no  time  has  there  been  any  fever  or  any  evidence  of  free  fluid  or  tuber- 
culous masses  in  the  abdomen.  Nor  do  we  get  any  very  distinct  help  in 
diagnosis  from  the  knowledge  that  she  has  been  alcoholic  at  times,  and 
that  she  apparently  had  a  very  poor  start  in  the  world.  Possibly  her 
alcoholism  may  have  something  to  do  with  her  mental  state  or  with  the 
various  pains  of  which  she  complains. 

The  darting  character  of  these  pains  and  their  distribution  correspond 
quite  accurately  with  the  "lightning  pains"  of  tabes.  The  physical  ex- 
amination as  it  is  here  reproduced  gives  us  no  evidence  wherewith  to 
support  or  to  attack  this  idea,  but  from  my  own  examination  of  the  case  I 
know  that  all  the  reflexes  were  normal. 

The  essential  symptoms  in  the  case  seem  to  me  at  the  present  time 
as  follows:  Right  iliac  pain,  accompanied  by  frequent  bowel  movements 
containing  much  mucus.  Occurring  in  a  patient  of  the  temperament  and 
physique  which  may  be  inferred  from  the  above  description,  these  symp- 
toms suggest  especially  the  condition  known  as  ^Uolica  mucosa^''  or 
mucous  colitis.  Three  types  of  this  disease  are  familiar  to  most  prac- 
titioners: {a)  Those  characterized  mostly  by  pain,  with  a  moderate 
amount  of  constipation  and  neurasthenia;  (b)  those  characterized  mostly 
by  constipation,  with  a  moderate  amount  of  pain  and  neurasthenia; 
and  (c)  those  characterized  mostly  by  neurasthenia,  with  a  moderate 
amount  of  constipation  and  pain. 

In  all  these  cases  the  stools  contain  varying  amounts  of  mucus, 
sometimes  mixed  with  fecal  matter,  sometimes  making  up  practically 
the  whole  of  the  dejection.  In  my  opinion,  however,  the  fundamental 
and  underlying  factor  in  all  cases  is  the  neurasthenic  state  which  is  the 
cause  of  the  constipation,  and  thereby  of  the  pain  and  mucus.  The  most 
successful  treatment  must  address  itself  to  the  cure  of  the  constipation, 
but  this  cannot  be  permanently  relieved  unless  the  patient's  mental 
habits  and  point  of  view  can  be  reconstructed. 

Outcome. — Under  treatment  for  constipation,  with  5  grains  of 
Blaud's  pills  three  times  a  day,  the  patient  was  discharged  relieved  on 
the  nineteenth  of  August. 

Diagnosis. — Mucous  coHtis. 

Case  136 

A  school-girl  seventeen  years  old  was  first  seen  December  4,  igo8. 
Six  days  before  she  had  a  stomachache,  which  lasted  about  twenty-four 
hours  and  then  got  better.  Three  weeks  before  she  had  had  a  similar, 
but  less  severe,  pain.  Since  then  she  has  had  similar  attacks  three  or 
four  times  a  dav. 


RIGHT   ILIAC    PAIN  27 1 

On  examination  the  temperature,  pulse,  and  respiration  are  normal; 
the  chest  negative,  the  abdomen  level,  generally  tender,  with  slight  mus- 
cular spasm  over  the  whole  right  side. 

The  last  menses  came  two  weeks  ago.  The  diet  has  been  blameless. 
The  present  attack  followed  immediately  after  some  high  jumping  in  the 
gymnasium.  The  pain  was  almost  as  great  in  the  back  as  in  front. 
The  bowels  moved  normally  during  three  days  of  observation.  The 
temperature  was  steadily  normal,  likewise  the  pulse.  Pain,  however, 
persisted  and  kept  her  awake  most  of  three  nights.  At  times  it  was 
rhythmic,  coming  every  fifteen  minutes  and  lasting  about  two  minutes. 
The  girl  and  her  family  were  all  well  acquainted  with  the  symptoms  of 
appendicitis,  and  much  afraid  of  it.  The  leukocytes  ranged  close  to 
io,cco.  Pressure  on  the  left  side  of  the  belly  caused  pain  in  the  a7)pen- 
dix  region.     Physical  examination  was  otherwise  wholly  negative. 

Discussion. — The  extension  of  pain  and  tenderness  to  the  back, 
the  absence  of  temperature,  elevated  pulse,  and  increased  leukocyte 
count,  and  the  aj^parcnt  relation  to  a  strain  at  the  time  of  the  onset, 
inclined  me  at  first  to  Ijclicve  that  this  case  was  due  to  a  wrench  either 
of  the  back  muscles  or  of  the  sacro-iliac  joint.  I  could  not  rule  out  the 
])Ossibility  of  a  ])ure  neurosis,  since  the  patient  was  an  excej)tionally 
liigh-strung  and  nervous  girl,  who  had  known  and  feared  appendicitis 
all  her  life.  Indeed,  this  diagnosis  was  furnished  to  me,  ready  made,  as  I 
entered  the  sick-room. 

But  against  both  these  possibilities  there  was  the  fact  that  the  pain 
was  not  relieved  either  by  a  com])lete  rest  in  bed  with  cross-stra])])ing  of 
the  back  and  elevation  of  the  lumbar  region  on  a  ])i]low,  nor  by  rejjcatod 
assurances  that  she  was  not  suiTering  from  a])pendicitis.  On  the  con- 
trary, the  pain  continued  with  very  little  abatement.  Heat  gave  it  only 
\ery  slight  relief;  asj)irin  was  equally  inefficacious.  Judgment  was 
still  more  affected,  however,  by  the  ])ain's  rhythmic  character,  which 
usually  indicates  spasm  j)roduced  in  some  hollow,  tubular  structure. 
This  could  not  fit  in  with  either  of  my  previous  diagnoses,  and  tlie  xenlict 
had  to  be  shifted  to  ap])endicular  colic.  At  no  time  was  tliere  any  in- 
dication of  an  in^•olvement  of  anv  part  of  tlie  urinary  tract.  The  ])ain 
nexer  followed  the  course  of  the  ureter,  nor  showed  any  of  tlic  typical 
radiations  of  ne])hrolitluasis.     The  urine  remained  whoih-  negati\e. 

Outcome. —  Operation,  D('ceml)er  8th,  showwl  an  a|)i)endix  bent 
u])on  itself,  and  coxered  witli  old  adhesions,  but  not  intlanKd. 

Diagnosis.— Ajipendicnlar  colic  (^chronic  a])i>cndicitis). 


272  DIFFERENTIAL   DIAGNOSIS 


Case  137 


A  Scottish  housewife  of  thirty-fi\e  was  first  seen  February  7,  1908. 
Her  family  history  is  good,  though  her  mother  died  of  cancer.  She 
had  polyarthritis,  with  fe\'er  and  prostration,  se\'en  years  ago  (soon  after 
marriage) . 

For  one  year  she  has  had  nearly  constant  pain  in  the  right  lower 
quadrant  of  the  belly.  There  is  no  colic,  but  the  steady  pain  often  needs 
morphin.  Pain  is  relieved  by  lying  down  and  always  disappears  at 
night.  She  sleeps  well  and  has  worked  until  three  weeks  ago.  She  is 
not  in  bed. 

Sometimes  the  pain  extends  down  the  right  leg,  but  it  has  no  other 
radiations.  No  jaundice.  No  urinary,  circulatory,  respiratory,  or  in- 
fectious symptoms. 

Examination. — -No  emaciation  or  anemia.  Visceral  examination 
was  negative  except  tliat  in  the  right  upper  quadrant  there  was  a  mass 
palpable  bimanually,  irregular  of  surface,  descending  to  the  navel  with 
inspiration.  Tenderness  of  right  lower  lumbar  muscles.  (See  Fig.  42. j 
Cutaneous  tuberculin  reactian  negative. 

A  catheter  specimen  of  urine  showed  microscopic  blood  and  pus. 
Cystoscopy  showed  a  normal  bladder.  Turbid  urine  was  oljtained  from 
the  right  ureter;  injected  into  a  guinea-pig;  five  weeks  later  negative 
autopsy. 

Discussion. — ^It  is  noticeable  in  this  case  that,  although  the  pain  is 
in  the  right  iliac  fossa,  the  tenderness  is  in  the  lumbar  region,  where  a 
m^ass  is  felt  bimanually.  The  fact  that  the  pain  disappears  when  the 
patient  lies  down  tends  still  further  to  connect  it  with  the  kidnc}-,  rather 
than  with  any  structure  in  the  neighborhood  of  the  cecum. 

Tumors  of  the  kidney  produce  pain,  enlargement  of  the  organ,  and 
often  a  urine  such  as  that  here  descril)ed,  but  it  would  be  unlikely  that 
the  amount  of  ]^us  would  l)e  so  large  in  ])roportion  to  the  amount  of 
blood.  There  has  been,  indeed,  no  true  hematuria,  and  after  a  year's 
duration  kidney  tumors  usually  produce  a  hematuria  so  profuse  as  to 
result  in  anemia.  Emaciation  would  proljably  be  present  also  by  this 
time. 

Renal  tuberculosis  would  explain  all  the  sym])toms,  though  it  usually 
does  not  gi\-e  rise  to  such  scNcre  and  long-standing  pain,  and  almost 
always  produces  bladder  symptoms,  which  are  not  complained  of  here. 
Nevertheless,  it  is  only  the  results  of  animal  inoculation  that  enable  us  to 
exclude  tuberculosis  in  this  case. 

Is  it  possible  that  a  simple  looseness  and  displacement  of  tlie  kidney 


I'ig.  42. — Position  of  the  mass  dcscrilied  in  Case  137. 


RIGHT  ILIAC   PAIN 


273 


could  produce  such  symptoms?  This  idea  is  favored  by  the  disappear- 
ance of  pain  in  the  recumbent  position,  but  we  do  not  expect  a  kidney, 
not  in  itself  diseased,  to  secrete  a  urine  turbid  with  blood  and  pus,  al- 
though when  the  kidney  gets  in  such  a  position  as  to  twist  its  blood-vessels, 
we  may  have  hematuria  from  congestion.  The  enlargement  here  present 
seems  sufficient  to  exclude  a  simple  floating  kidney. 

The  important  evidence  which  we  still  lack  is  that  obtainable  through 
the  x-TSL}'  examination  of  the  kidneys  with  special  reference  to  stone.  The 
only  point  disdnctly  against  stone  here  is  the  absence  of  any  colic.  The 
good  preservation  of  nutrition  is  more  in  harmony  with  the  diagnosis  of 
nephrolithiasis  than  with  any  other  condidon  producing  enlargement  of  the 
kidney.  It  is  not  easy  to  see  just  why  the  kidney  should  be  enlarged  as 
the  result  of  stones  in  the  pelvis,  unless  there  were  obstruction  to  the  flow 
of  urine,  a  complication  of  which  we  have  no  e\idence  here.  Yet  it  is 
a  very  familiar  fact  that  kidneys  which  turn  out  to  be  the  seat  of  no 
disease  other  than  nephrolithiasis  uncomplicated,  seem  considerably 
enlarged  when  palpated  before  operation. 

Outcome. — X-ray  shows  stones  in  both  kidneys. 

Operation :  in  right  kidney  a  stone  with  a  body  the  size  of  a  plum 
and  three  branches  one  inch  long  was  found;  in  left  kidney  three  stones, 
the  largest  as  large  as  a  marble,  the  smallest  the  size  of  a  marrow- fat 
pea.       November  12th:  Discharged  well. 

Diagnosis. — Stone  in  both  kidneys. 

18 


274 


DIFFERENTIAL   DIAGNOSIS 


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Inguinal  hernia,  the  debihty  of  neurotic  women,  and  the  temporary 
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pain  are  also  to  be  mentioned. 


27fi 


CHAPTER  IX 


LEFT  ILIAC  PAIN 


Case  138 


A  HOUSEWIFE  of  forty-six  was  seen  in  consultation  May  lo,  1907. 
The  attending  physician's  diagnosis  was  cancer  of  the  intestine,  probably 
in  the  sigmoid.  The  patient  has  had  for  three  or  four  years  a  "stomach 
trouble"  characterized  by  pain  near  the  left  costal  margin,  with  vomiting 
of  greenish  fluid  and  "coffee-grounds,"  the  vomitus  being  sometimes 
sour,  sometimes  bitter.  Vomiting  relieved  the  pain.  For  the  past  year 
she  has  had  no  vomiting  and  only  moderate  soreness  in  tlie  left  side. 
Six  weeks  ago  she  felt  a  sudden  knife-like 
pain  in  the  left  laurr  ojiadrant,  which  lasted 
twenty-four  hours,  following  which  she  was 
in  bed  for  five  weeks.  The  bowels  moved 
e^■ery  second  day.  She  has  lost  five  or  six 
pounds. 

Physical  examination  showed  fair  nutri- 
tion; marked  pallor.  Red  cells,  3,332,000; 
hemoglobin,  50  per  cent.;  j)olynuclcar  cells, 
52  per  cent.;  considcral)le  achromia;  urine 
negati^■e;  chest  negative.  Above  and  to  the 
left  of  the  umbilicus  a  hard,  movaljle,  sausage- 
shaped  mass,  extending  from  the  median  line 
obli(|ucly  outward  and  downward  for  three 
inclies. 

A  stomach-tul)c  showed  no   fasting  con- 
tents and  no  enlargement  of  tlie  organ.    After 
a  test-meal,  free  IlCl  was  0.2S  per  cent.;  total 
acidity,  0.35  ])ercent 
and  intestinal  contents. 

The  diagnosis  of  cancer  of  tlie  sigmoid  was  generally  agreed  to. 

Discussion. — At  least  three  vears  of  a  st(nuach  trouble  which  lias 
produced  anemia  and  liy])erchlorh\"(lria,  but  which  has  not  led  t(^  a.ny 
jiastric  stasis — such  is  the  backurouud  auainst  which  the  recent  -MiT'toms 


I'ig.  4:;.-    Chart  nf   case   i  :;S. 

The  guaiac  test  was  negative,  botli  in  the  gastric 


278  DIFFERENTIAL  DIAGNOSIS 

of  this  case  stand  out.  A  sudden  acute  attack  of  left  iliac  pain  and  in 
the  same  region  a  tumor,  regarding  the  age  of  which  we  have  no  knowl- 
edge, are  the  facts  which  must  in  some  way  be  woven  into  a  satisfactory 
diagnosis. 

With  such  a  tumor  and  such  a  pain,  a  diagnosis  of  sigmoid  cancer 
seems  at  first  inevitable.  But  a  cancer  which  has  existed  long  enough 
to  be  palpable  as  a  tumor  of  this  size  should  also  manifest  itself  by  visible 
peristalsis,  intestinal  noise,  gross  or  occult  blood  in  the  stools,  diarrhea, 
or  marked  constipation.  That  none  of  these  symptoms  is  present  should 
certainly  give  us  pause. 

Were  the  tumor  situated  higher  up  in  the  abdomen,  we  should  cer- 
tainly be  inclined  to  consider  a  perigastric  exudate  resulting  from  the 
attempt  of  a  gastric  ulcer  to  perforate.  The  long  previous  history,  the 
present  hyperchlorhydria,  the  anemia,  and  the  recent  acute  attack  of  pain 
are  all  quite  consistent  with  this  diagnosis.  It  seems  somewhat  remark- 
able, however,  that  the  symptoms  should  have  come  to  so  complete  a 
standstill  as  has  apparently  occurred  since  the  attack  six  weeks  ago. 

Though  nothing  is  said  in  the  text  regarding  the  results  of  pelvic 
examination,  I  may  add  here  that  nothing  could  be  found  in  the  pelvis 
to  connect  any  of  its  organs  with  the  disease  under  consideration. 

Outcome.— On  the  twenty-first  of  May  the  abdomen  was  opened. 
The  mass  proved  to  be  composed  of  a  perigastric  exudate  adherent  to 
the  abdominal  wall.  Behind  this  was  the  narrow  neck  of  an  hour-glass 
stomach,  which  barely  admitted  the  little  finger  and  was  e\'idently  due 
to  the  scar  of  an  old  gastric  ulcer.  Gastro-enterostomy  was  done.  Six 
days  after  operation  the  patient  was  doing  well. 

Diagnosis. — Perforated  gastric  ulcer. 

Case  139 

A  housewife  of  twent}'-six  entered  the  hospital  December  27,  1906. 
For  two  months  she  has  been  having  pain  in  the  left  iliac  region,  at 
first  darting  in  character  and  extending  through  to  the  back;  later,  dull 
and  constant,  sometimes  more  severe  at  night.  Pain  has  been  accom- 
panied by  weakness  and  frequent  micturition.  Her  appetite  has  been 
good,  her  bowels  regular,  her  urine  dark  and  cloudy  for  a  month. 

The  course  of  the  temperature  is  seen  in  tlie  accompanying  chart. 
The  urine  was  alkaline  and  contained  always  a  large  amount  of  pus.  and 
sometimes  a  great  deal  of  blood  in  clots.  The  specific  gravity  was  always 
low,  averaging  about  1012,  and  the  amount  of  albumin  large;  no  casts 
were  ever  found.  Examination  of  the  chest  and  abdomen  was  negati\'e; 
likewise  .v-rav  examination  of  the  renal  regions.     After  entrance  to  the 


LEFT   ILIAC    PAIN 


279 


hospital  the  urine  was  sometimes  quite  normal,  at  other  times  composed 
almost  wholly  of  blood.  Several  small  concretions  were  passed  in  the 
early  days  of  January,  1907.  On  the  sixth,  one  obstructed  the  urethra 
and  had  to  be  removed.  It  was  shown  to  be  composed  of  calcium  jihos- 
phate  upon  a  nucleus  of  mucin.  Its  pas- 
sage was  not  attended  with  pain.  Re- 
peated examinations  of  the  urinary  sedi- 
ment showed  no  tubercle  bacilli. 

Discussion. — The  essential  features 
of  this  case  are  left  iliac  pain  of  two 
months'  duration,  associated,  during  the 
past  month,  with  the  frequent  passage 
of  an  alkaline,  cloudy  urine  containing 
large  amounts  of  pus  and  blood.  The 
continued  fever  is  also  of  importance. 

All  these  symj)toms  may  be  produced 
by  renal  tuberculosis,  and  this  diagnosis 
cannot  be  possibly  excluded  upon  the  evi- 
dence here  presented.  Animal  inoculation 
is  necessary.  Nevertheless,  the  absence 
of  any  evident  enlargement  of  the  kidney, 
demonstrable  by  ]:)ali)ation  or  rc-ray  ex- 
amination, the  presence  of  an  alkaline 
urine,  and  the  constant  abundance  of  blood,  are  facts  which  tend  to 
su{)port  the  negative  results  of  the  search  for  tubercle  bacilli. 

In  the  hands  of  a  com})etent  operator  we  may  say  that  .r-ray  examina- 
tion, declared  by  him  to  be  negative,  is  very  strong  evidence  against  the 
existence  of  renal  stone.  The  })rcdominance  of  bladder  symptoms  here, 
the  absence  of  anything  suggesting  colic,  and  the  apparently  steady  dis- 
charge of  l)lood  and  pus  tend  to  rule  out  nc|)hrolithiasis. 

Malignant  disease  of  the  kidney  rarely  produces  such  a  ])redomin- 
ancc  of  bladder  symptoms  or  so  large  an  amount  of  ])us  in  the  urine. 
Unless  we  supj)Ose  the  neoplasm  to  be  complicated  by  bladder  disease, 
we  could  not  account  for  the  alkalinity  of  the  urine. 

Stone  in  the  bladder  is  rare  in  women  if  we  Iea\"e  out  of  account  tl-.e 
secondary  calculi  incrusted  about  a  hair-})in  or  some  other  foreign  body. 
There  is  no  history  of  th.c  introduction  of  any  such  body  in  this  case,  ar.d 
if  we  take  the  history  on  its  face  value,  this  is  exidence  against  1  hiddrr 
stone.  In  one  sense,  of  course,  we  are  quite  sure  that  stones  ha\c'  been 
in  the  bladder,  since  several  small  ones  haw  been  ])asse(l;  hut  troni  the 
rarity  of  ijrimary  bladder  calculi  in  women  ;ind  the  ahseute  of  an\"  ot  tb.e 


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28o  DIFFERENTIAL   DIAGNOSIS 

exacerbations  due  to  jolting  or  moving,  we  may  suppose  that  the  small 
stones  which  have  emerged  were  formed  as  a  secondary  result  of  some 
other  disease.  The  question  remains  as  to  what  that  disease  is  likely  to 
be. 

Chronic  cystitis  is  now  universally  recognized  to  be,  in  practically 
all  cases,  a  symptom  of  some  deeper  cause.  The  days  of  primary  or 
idiopathic  cystitis  are  passed.  Gonorrheal  cystitis  is  distinctly  rare 
unless  as  a  part  of  a  much  more  obvious  acute  and  general  infection  of 
the  genito-urinary  tract. 

Tuberculosis  of  the  bladder  is  a  frequent  cause  of  cystitis,  and  is 
practically  always  secondary  to  renal  tuberculosis,  reasons  for  excluding 
which  have  been  already  gi\'en. 

Tumor  of  the  bladder  is  the  only  remaining  cause  of  cystitis  fre- 
quently occurring  in  women,  and  against  that  diagnosis  there  seem  to  be 
no  important  data.  The  occurrence  of  small  concretions  in  and  about 
tumor  of  the  bladder  is  a  familiar  fact. 

Outcome. — On  the  twenty-third  cystoscopy  showed  an  exceedingly 
foul  bladder  and  a  ragged  tumor  mass  on  the  left  side.  Operation  on 
the  twenty-sixth  confirmed  this  diagnosis.  A  cutting  from  the  mass 
was  examined  histologically  and  pronounced  undoubtedly  malignant. 
The  walls  of  the  bladder  were  much  thickened  and  contracted. 

Diagnosis. — Bladder  cancer. 

Case  140 

A  laundress  of  forty-four  entered  the  hospital  December  24,  1907. 
She  had  lost  one  sister  of  consumption;  her  family  history  was  otherwise 
good.  She  has  been  subject  all  her  life  to  occasional  sick  headaches. 
At  half-past  nine  this  morning,  while  washing,  she  suddenly  began  to 
have  steady,  severe  pain  half-way  between  the  navel  and  the  left  flank. 
Soon  after  she  vomited  her  breakfast.  The  pain  was  so  severe  that 
she  could  not  lie  down  until  night.  Her  suffering  has  been  constant, 
though  varying  in  intensity,  and  she  has  continued  to  vomit  a  thin,  yel- 
lowish fluid.  There  is  some  soreness  in  the  region  of  the  pain,  but  no 
headache  at  the  present  time.  The  bowels  mo\'ed  two  days  ago  with 
medicine,  not  since.  She  has  been  very  constipated  for  years,  sometimes 
going  a  week  without  a  movement. 

Physical  examination  of  the  chest  was  negative  save  for  accentuation 
of  the  aortic  second  sound.  The  urine  and  blood  were  normal.  The 
right  kidney  descended  two  fingers'  breadth  below  the  costal  margin 
on  full  inspiration.  During  the  first  two  days  in  the  hospital  the  patient 
vomited  cA'crytlfing  that  was  taken  by  mouth.     Finally,  the  bowels  were 


LEFT   ILIAC    PAIN  281 

started  by  calomel  and  enemata,  and  by  the  twenty-seventh  the  patient 
was  taking  milk  and  feeling  happy.  The  first  urinary  examination 
showed  sugar,  acetone,  and  diacetic  acid.  After  that  there  was  no  sugar, 
but  acetone  and  diacetic  acid  persisted  until  the  twenty-eighth. 

Discussion. — The  chronic  constipation  leading  to  acute  pain  and 
obstinate  vomiting  cannot  but  incline  us  very  strongly  toward  the  diag- 
nosis of  sigmoid  cancer,  especially  since  the  woman  is  forty-four  years 
old.  But  what  are  we  to  say  when,  after  we  have  made  such  a  diagnosis, 
we  succeed  in  getting  the  patient's  bowels  to  move  naturally  and  all 
the  symptoms  disappear?  I  have  introduced  this  case  in  order  that  I 
might  emphasize  the  point  that  such  a  recovery  by  no  means  excludes 
cancer.  In  the  early  stages  of  that  disease,  when  the  growth  is  little 
bigger  than  a  signet  ring,  temporary  obstruction  with  fecal  impaction 
behind  the  stricture  often  leads  to  symptoms  quite  like  those  here  de- 
scribed, which,  nevertheless,  disappear  under  treatment  and  may  not  re- 
cur for  weeks  or  months.  It  is  only  by  a  careful  following  of  the  case 
that  we  can  be  justified  in  excluding  cancer. 

Outcome. — On  the  first  of  January  sugar  was  again  present  in  the 
urine.  On  the  second  it  was  gone  and  did  not  return,  although  the  i)a- 
tient  was  allowed  a  full  mixed  diet.  Thereafter  the  patient's  bowels 
were  kept  regular  by  the  use  of  an  A.  S.  and  B.  pill  four  times  a  day. 
There  has  been,  so  far  as  known,  no  return  of  symptoms. 

Diagnosis. — Constipation. 

Case  141 

A  hostler  of  thirty- two  entered  the  hospital  June  3,  1902.  His 
family  history  and  past  history  were  negative.  Until  the  prexious 
fall  he  had  always  taken  five  or  six  beers  and  three  or  four  whiskies  a  day. 
He  denied  venereal  disease.  Yesterday  morning  he  awoke  with  a  chill, 
chattering  teeth,  fever,  vomiting,  headache,  and  pain  in  the  left  groin. 
He  slept  poorly  last  night.  The  course  of  the  temperature  was  as  seen 
in  the  accompanying  chart.  On  the  sixth  the  glands  were  disc()\"ered 
to  l)e  tender  and  considerably  enlarged  in  the  left  groin.  There  was 
an  operation  scar  over  the  u])|)er  j)art  of  the  left  tibia;  the  bone  under- 
neath it  very  rough.  Below  this  the  skin  was  bluish  red,  and  sewral 
ulcerated  areas  from  the  size  of  a  silver  dollar  to  that  of  the  p;ihn  were 
present.  An  .v  ray  sliowed  tluit  the  tilna  was  consideral)!}'  tliickeni'd 
in  its  upper  third,  and  tlie  fil)ula  throughout  its  entire  length.  I'h_^^ical 
examination,  including  the  blood  and  urine,  was  otherwise  negatiw. 

Discussion. -This  storv  seems  to  narrow  itseU"  don  11  to  a  ra>e  of 
fcM'r  witli  ]>ainful  glands  in  the  groin.     Our  cliief  task  is  to  con-ider  the 


282 


DIFFERENTIAL  DIAGNOSIS 


probable  cause  of  the  glandular  enlargement.  The  ulceration  on  the 
lower  leg  may  well  produce  sufficient  irritation  to  stimulate  the  glands 
into  a  work-hypertrophy,  ordinarily  known  as  a  bubo.  Leukemia 
being  ruled  out  by  the  negative  result  of  the  blood  examination,  and 
pseudoleukemia  l^y  the  absence  of  glandular  enlargement  elsewhere, 
it  remains  only  to  consider  the  probable  nature  of  the  ulcerations  which 

have  led  to  the  adenitis  and  so  to  the  pain 
and  fever. 

Ulcerations  in  this  situation  are  most 
frequently  due  to  the  malnutrition  following 
varicose  veins,  hence  the  term  varicose  ulcer. 
Next  to  this,  syphilis  is  the  most  common 
cause,  though  it  is  more  apt  to  produce  ulcera- 
tions in  the  calf  or  above  the  knee  than  upon 
the  shin.  In  view  of  the  x-ray  evidence, 
which  shows  a  bony  change  very  commonly 
associated  with  syphilis,  this  seems  the  most 
reasonable  diagnosis. 

Regarding  the  cause  of  the  acute  infec- 
tion,  with  its  attendant  pyrexia  and  chill, 
nothing  very  definite  can  be  said.     Possibly 
there  was   some  secondary  invasion  of  the 
tissues  induced  by  a  sudden  lowering  of  their 
vitality,  for  which  there  are  many  occasions 
in  the  life  of  such  an  individual. 
Outcome. — Under  iodid  of  potash  the  glands  became  smaller,  the 
fever  went  down,  the  leg  ulcers  began  to  heal;  on  the  fourteenth  the 
patient  was  discharged. 

Diagnosis. — Syphilitic  adenitis. 


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Case  142 

A  housewife  of  twenty-seven  entered  the  hospital  June  21,  1908,  for 
pain  in  the  left  iliac  fossa,  her  second  se\'ere  attack  within  three  weeks. 
The  first  attack  (twenty  days  ago)  was  very  severe,  but  lasted  only  about 
one  minute.  Yesterday  at  2  a.  m.  sudden  severe  pain  began  again  at  the 
same  point,  lasted  until  10  a.  m.,  then  suddenly  ceased  until  this  morn- 
ing about  five,  when  it  returned  as  she  was  getting  up.  At  times  she  has 
seen  and  felt  a  swelling  in  the  region  of  the  pain. 

She  has  had  three  children,  the  youngest  three  months  old.  ^Menses 
normal.     Xo  other  illnesses. 

Examination. — Abdomen  prominent  in  lower  left  quadrant,  where 


LEFT   ILIAC    PAIN 


283 


there  are  circumscribed  dulness  and  a  large,  hard,  irregular  mass,  mov- 
able and  very  tender.  It  was  apparently  not  connected  with  the  uterus, 
but  could  be  felt  per  vaginam.  Physical  examination,  pulse,  tempera- 
ture, blood,  and  urine  negative. 

Discussion. — The  association  of  left  iliac  pain  with  a  hard,  irregular 
mass  in  the  same  region  naturally  suggests  malignant  disease.  The 
sigmoid  flexure  of  the  intestine  is  the  commonest  site  for  such  a  growth 
in  this  part  of  the  body,  and  the  age  of  the  patient  by  no  means  excludes 
this  possibility.  I  have  seen  a  cancer  of  the  sigmoid  demonstrated  at 
autopsy  in  the  body  of  a  boy  who  died  before  his  twenty-first  year. 
In  the  present  case,  however,  we  have  no  intestinal  symptoms  sufficient 
to  incriminate  the  sigmoid,  and  a  growth  of  the  size  above  described 
would  certainly  have  produced  such  symptoms  if  the  gut  were  in\-ol\ed. 

0\-arian  tumor  seems  more  probable.  Wc  do  not  expect  the  com- 
moner varieties  of  o\-arian  tumor  to  be  as  firm  of  surface  as  the  descrip- 
tion of  this  tumor  suggests,  but  I  ha\-e  often  been  decei\'ed  in  this 
respect  and  seen  at  operations  a  cystic  tumor  which  felt  as  hard  cs  a  piece 
of  wood  when  examxined  through  the  abdominal  wall,  so  that  I  am  no 
longer  willing  to  trust  m}'  tactile  sensations.  Solid  tumors  of  the  o\ary 
are  considerably  less  common,  especially  in  women  of  this  age,  and  rarely 
reach  so  large  a  size  without  pre\-iously  attracting  any  attention.  Fibro- 
myoma  of  the  uterus  would  probably  show  an  obvious  connection  with 
that  organ  and  would  be  less  likely  to  be  situated  so  much  at  one  side. 

Uncomplicated  ovarian  tumors  do  not  produce  acute  symjjtoms  like 
those  above  described,  but  there  are  many  accidents  to  which  such 
tumors  are  exposed  and  by  which  severe  pain  may  Ijc  produced.  As 
we  have  no  way,  in  the  great  majority  of  cases,  of  distinguishing  these 
accidents  clinically,  it  is  safest  to  assume  that  the  commonest  of  them 
— twisting  of  the  pedicle — has  occurred. 

Outcome. — Operation  showed  a  gangrenous,  strangulated,  multi- 
lociilar  ovarian  cyst  with  a  double  twist  in  its  [)edicle  and  a  quart  of  blood- 
serum  in  the  peritoneal  cavity. 

It  may  be  well  to  mention  here  some  of  the  A'arietics  in  the  symijto- 
matology  of  strangulated  ovarian  cyst,  so  as  to  bring  out  features  not 
exemj)hfied  in  the  case  just  discussed. 

{a)  In  many  cases  there  are  repeated  attacks  wl-.ich  are  clinic;. lly 
similar  in  ty])e,  but  lesser  in  intensity  than  that  ab()\e  described.  Many 
of  these  attacks  are  due,  douljtless,  to  ])atches  of  local  ])eritonitis  such  as 
result  in  the  adliesions  which  often  confront  the  operator  years  kiler. 

{b)  General  abdominal  tenderness  and  s]xisni.  associated  \\\\\\  \"oinit- 
ing  and  great  jjrostration,  often  make  the  ehnical  picture  nv.;ch  lil-e  that 


284  DIFFERENTIAL  DIAGNOSIS 

of  acute  peritonitis,  which  can  be  excluded  only  when  the  patient  or  her 
physician  has  previously  known  of  the  tumor's  existence. 

(c)  Tumors  occupying  the  right  side  of  the  abdomen  are  fully  as 
common  as  left-sided  growths.  In  a  considerable  proportion  of  cases  the 
cyst  is  to  be  found  in  the  median  line,  and  the  diagnosis  is  thereby  con- 
siderably obscured. 

((l)  Moderate  fever  and  leukocytosis  are  the  rule,  the  former  ranging 
between  100°  and  102°  in  most  cases,  while  the  leukocytes  are  usually 
between  14,000  and  20,000. 

(c)  If  menstruation  occurs  during  such  an  attack  of  pain,  the  latter 
is  often  relieved. 

Diagnosis. — Multilocular  ovarian  cyst  (twisted  pedicle). 

Case  142a 

A  widow  of  sixty-seven  called  her  physician  in  September.  1908, 
on  account  of  pain  in  the  left  iliac  fossa.  For  five  or  six  years  she  has 
noted  a  bloody  discharge  wath  some  odor.  This  discharge  has  been 
supposedly  due  to  hemorrhoids  and  has  been  treated  as  such,  but 
examination  now  shows  it  to  come  from  the  vagina.  For  the  past 
week  this  discharge  has  been  active  and  the  blood  has  been  bright. 
Four  weeks  previously  to  this  time  she  had  a  wreck's  flowing,  and 
similar  periods  have  occurred  from  time  to  time  during  the  last  five 
years. 

The  present  illness  began  three  weeks  ago  with  pain,  tenderness, 
and  enlargement  of  the  left  lower  quadrant  of  the  abdomen,  accom- 
panied by  fever  which  averaged  101°  F.  for  the  first  week  of  her 
illness.  This  gradually  fell  to  normal,  so  that  ten  days  ago  the 
local  physicain  was  able  to  discontinue  his  visits  for  three  days. 
With  the  subsidence  of  temperature  the  w^eakness,  tenderness,  and 
pain  of  which  she  had  previously  complained  gradually  disappeared, 
but  a  week  ago  all  the  symptoms  returned,  and  during  the  last  six 
days  fever  has  averaged  100°  F.  The  pain  is  now  referred  not  only 
to  the  left  iliac  fossa,  but  to  the  left  thigh  and  hamstring  muscles. 
The  bowels  are  moved  by  enema. 

The  appetite  has  been  very  poor  and  there  has  been  marked 
prostration,  so  that  she  has  been  in  bed  most  of  the  time  during  the 
last  four  weeks.  Her  weight  has  fallen  considerabley.  There  has 
been  no  vomiting,  no  cough,  and  no  pain  other  than  that  described 
above.     The  menopause  occurred  thirteen  years  ago. 

\\'hen   seen   in   consultation   October   19,  1910,  the  patient's  tern- 


LEFT    ILIAC    PAIN  285 

perature  was  101.2;  there  was  moderate  emaciation;  at  the  apex  of 
the  right  lung  the  physiologic  peculiarities  of  that  space  on  auscul- 
tation and  percussion  seemed  somewhat  exaggerated.  Otherwise 
the  chest  showed  nothing  abnormal.  The  left  lower  quadrant  of  the 
abdomen  was  filled  by  a  smooth,  resistant,  apparently  elastic  mass, 
protected  by  a  considerable  amount  of  muscular  spasm  and  rather 
tender.  The  same  mass  was  felt  by  vagina,  but  seemed  to  be  un- 
connected with  the  uterus,  which  was  normal. 

The  leukocytes  numbered  25,600,  90  per  cent,  of  which  were 
polynuclears.     There  was  no  anemia.     The  urine  was  normal. 

Three  weeks  later  the  attending  physician  reported  that  the 
patient  was  about  the  same,  the  temperature  still  reaching  about 
101°  F.  each  night,  being  normal  or  subnormal  in  the  morning.  There 
was  then  very  little  pain  and  the  vaginal  discharge  had  ceased. 

Discussion. — Cancer  of  the  uterus  was  first  suspected  on  ac- 
count of  the  ill-smelling  vaginal  discharge.  That  this  was  not  of 
the  ordinary  type,  involving  the  cervix  uteri,  was  readily  shown  by 
the  vaginal  examination.  Cancer  of  the  body  of  the  uterus  was  not 
excluded,  as  no  intra-uterine  examination  was  made.  It  is  very 
unlikely,  however,  that  so  much  fever  and  left  iliac  tenderness  would 
be  produced  by  a  neoplasm  of  the  body  of  the  uterus. 

Cancer  of  the  sigmoid  was  next  considered.  The  position  of  the 
tumor  mass,  the  age  of  the  patient,  and  the  presence  of  a  bloody  dis- 
charge, which  the  patient  believed  to  have  come  from  the  rectum, 
favored  this  diagnosis.  On  the  other  hand,  nothing  definite  could  be 
felt  by  rectum.  There  was  no  evidence  of  intestinal  obstruction  and 
no  diarrhea,  while  the  presence  of  continued  fever  for  more  than  a 
month  made  uncom[)licated  neoplasm  very  unlikely.  The  same 
holds  true  of  ovarian  neoplasm.  P)osalpinx  was  considered,  but 
seemed  exceedingly  unlikely  in  view  of  the  patient's  age  and  char- 
acter. 

Diverticulitis  is  strongly  suggested  by  all  the  facts  of  the  case. 
The  age  of  the  patient,  the  position  and  consistency  of  the  tumor, 
and  the  continued  fever  with  leukoc^'tosis  are  tyi)ical. 

Outcome.  On  operation,  November  i,Uh,  a  large  intlammatory 
mass  was  foimd  txing  together  the  bladder,  the  lower  sigmoid,  and  tlu' 
adjoining  ])arts.  In  the  center  of  the  mass,  close  to  the  sigmoid,  a 
pus-ca\'itv  containing  about  a  tablesjioonful  of  pus  was  tound.  Lead- 
ing out  of  this  ca\'ity  was  a  sinus  conm'cting  with  thi'  interior  ot  the 
lower  sigmoid,  which  was  greatly  thiekent'd  and  inliltrated  tur  ;i 
considerable    distance    al)o\"c    and     below     the    >inu>.      Miein-eoni/ 


286  DIFFERENTIAL   DIAGNOSIS 

examination  later  showed  that  the  sinus  originated  in  a  diverticulum. 
The  pus  was  evacuated  and  drained,  a  portion  of  the  sigmoid  resected, 
and  an  end-to-end  suture  done.  The  patient  made  a  somewhat  slow, 
but  uninterrupted  recovery. 

Diagnosis. — Diverticulitis  of  the  sigmoid. 

GENERAL    CONSIDERATIONS    ON    THE    DIAGNOSIS    OF    ABDOMINAL 

PAIN 

Though  I  have  followed  current  practice  in  separating  the  causes  of 
localized  from  those  of  generalized  abdominal  pain,  it  must  l)e  admitted 
that  the  separation  is  not  always  true  to  fact.  Diseases  like  appendi- 
citis, whose  pain  belongs  in  the  right  iliac  fossa,  are  very  apt  to  set  their 
pain  loose  all  over  the  belly.  On  the  other  hand,  lead-poisoning,  which 
usually  causes  wide-spread  "dry"  bellyaches,  may  anchor  its  colic  to 
a  single  spot  in  a  most  misleadim^  way. 

Hence  one  who  looks  under  one  chapter  for  some  familiar  type  of 
pain  may  wonder  at  its  absence  and  be  surprised  to  find  it  in  another. 
Some  causes  of  suffering,  on  the  other  hand,  are  listed  under  two  different 
headings  {e.  g.,  ectopic  gestation,  strangulated  ovarian  cyst),  because 
they  are  about  equally  common  on  the  right  and  on  the  left. 

When  searching  out  and  thinking  out  the  probable  cause  of  an  ab- 
dominal pain  we  are  all  guided,  I  take  it,  by  the  following  obvious  rules: 

1.  Suspect,  first  of  all,  the  gastro-intcstinal  tract,  and  if  its  simpler 
troubles  (such  as  constipation  and  colitis)  can  be  excluded,  consider 
especially  appendicitis,  peptic  ulcer,  neoplasms  cf  the  stomach  or  large  gut, 
and  the  remoter  consequences  of  these  lesions  (peritonitis,  intestinal 
obstruction). 

2.  Suspect  next  (in  women)  the  genital  tract  (pus-tube,  ovarian  cyst, 
uterine  fibroid,  ectopic  gestation) . 

3.  The  gall-bladder  and  its  ducts  are  especially  to  be  considered  if 
the  patient  is  past  middle  life. 

4.  The  urinary  tract,  especially  in  elderly  men  or  young  girls,  comes 
next  in  the  order  of  causes  for  abdominal  pain. 

In  investigating  any  of  these  causes  the  history,  palpation,  the  blood, 
the  urine,  .v-ray,  and  cystoscopy  are  the  most  valua1)le  aids. 


LEFT    ILIAC    PAIN 


287 


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CHAPTER  X 

AXILLARY  PAIN 

Case  143 

A  STABLEMAN  of  thirtv-ninc  entered  the  hospital  January  24,  1908, 
with  negative  family  history  and  good  habits.  Past  history  uneventful 
except  for  an  attack  of  malaria  in  September,  1907.  Three  days  ago, 
while  at  work,  he  had  a  severe  chill.  He  went  home,  but  did  not  go  to 
bed.     The  next  morning  he  went  to  work  as  usual,  but  had  to  give  up 

about  noon  and  take  to  bed,  where 
he  has  remained  since,  with  head- 
ache, high  fever,  pain  in  the  left 
chest,  sore  throat,  nausea,  thirst, 
and  frequent  vomiting.  His 
bowels  were  moved  by  laxatives 
this  morning.  AMicn  he  swallows, 
he  sometimes  feels  a  sharp  pain 
which  shoots  from  his  throat  to- 
ward his  left  ear. 

The  patient's  temperature  is 
seen  in  the  accompanying  chart. 
At  entrance  he  was  breathing 
easily,  and  there  was  no  motion 
of  the  nostrils.  He  complained 
of  deafness  and  buzzing  in  his 
ears,  especially  the  left.  There 
was  internal  strabismus  on  the 
right,  which  he  says  is  of  long 
standing.  There  was  a  mild  spasmodic  cough,  but  no  sputa.  \'isceral 
examination  was  negative,  save  that  in  the  lower  left  back  there  was  a 
little  dulness,  and  the  voice-sounds  were  a  trifle  nasal  in  character. 
Just  below  the  scapula  the  breath-sounds  were  somewhat  diminished, 
whispered  voice  slightly  increased,  and  an  occasional  clicking  rale  was 
audible.     No  bronchial  breathing. 

The  white  cells  were  20,000;  urine,  32  ounces;  specific  gravity,  1023. 
There  were  a  few  hyaline,  many  line  granular  casts,  and  a  slight  trace  of 
albumin. 


rig.  46. — Chart  of  case  143. 


2s-i 


Causes  of  Axillary  Pain 

1,  FLATULENCE     LEFT  AXILLA  AND   PRECORDIA" 

IHaHi^^^^^HlH^^^^i^^^^lBBBH    1013 


3.  PNEUMONIA  ^■■■■■■■■^^^■■■■IHB  803 

4.  FRACTURED  RIB       ■■■I^H  234 

5.  INTERCOSTAL\ 

NEURALGIA    i 

6.  RADIATIONS"! 

FROM    HYPER- 

TROPHICl-B  45 

SPINAL    A  R-  I 

THRITIS  J 

Among  other  lesions  not  grapliically  represented  liere,  because  of 
their  rarity  as  causes  of  axillary  pain,  are  : 

I  lerpes  zoster. 

Costal  tuberculosis. 

Costal  neoplasm. 

Costal  actinomycosis. 

Angina  pectoris. 

Deep  axillary  abscess. 
Fractures  and  dislocations  of  the  shoulder  and  humerus  often  pro- 
duce axillar)'  pain,  but  usualK'  present  no  diagnostic  difficulties  so  for 
as  the  source  of  the  pain  is  concerned. 

Final!}',  there  is  a  large  group  of  axillarx'  j)ains,  apparent}}"  of  mus- 
cular origin,  akin  to  lumbago  and  "  stiff  neck."  The  bombastic  term 
"  pleuroch-nia"  is  often  attached  to  tlu'se  pains,  but  since  their  actual 
nature  is  unknown  antl  their  diagnosis  never  certain,  I  have  attempted 
no  estimate  of  their  relatix'e  freciuencx'. 


I!t 


AXILLARY    PAIN  29 I 

Discussion. — Obviously,  we  are  dealing  with  an  infectious  disease, 
though  gastric  symptoms  occupy  the  foreground  of  the  clinical  picture. 
For  simple  tonsillitis  the  patient  is  apparently  too  sick,  and  there  was 
nothing  in  the  tonsillar  region  sufficient  to  justify  the  diagnosis. 

The  deafness,  the  buzzing  sounds,  and  the  shooting  of  pain  toward 
the  ear  might  indicate  otitis  media,  but  unless  pain  is  more  definitely 
localized  and  continuous  in  or  about  the  ear,  one  could  not  make  such  a 
diagnosis  in  the  absence  of  any  discharge  or  any  knowledge  of  the  con- 
dition of  the  drum  membrane. 

Acute  meningitis  may  begin  in  this  way,  and  there  is  nothing  said 
in  the  text  regarding  the  condition  of  the  neck  muscles  or  of  the  ham- 
strings (Kernig's  sign).  The  strabismus  would  be  of  great  diagnostic 
importance  if  we  disregarded  the  patient's  statement  that  it  has  existed 
for  many  years.  As  a  matter  of  fact,  however,  investigation  showed  that 
there  was  no  stiffness  of  the  neck  or  of  the  ham-string  muscles.  Without 
lumbar  puncture  no  further  certainty  can  be  obtained  on  this  point, 
and  meningitis  must  remain  a  possibility  unless  we  can  find  some  more 
plausible  explanation  for  the  sym|)toms. 

It  was  suljsecjuently  learned  that  the  patient  had  been  given  large 
doses  of  quinin  before  he  entered  the  hosijital,  the  chill  and  the  previous 
attack  of  malaria  having  led  to  the  exhibition  of  this  drug. 

Although  the  i)ulmonary  signs  are  very  slight  and  not  distinctive, 
they  seem  to  me  sufiicient  to  warrant  a  diagnosis  of  j)neumonia  when 
we  link  them  with  the  continued  fever,  the  leukocytosis,  the  chest  pain, 
the  chill,  and  the  gastro-intestinal  symptoms.  Cases  of  pneumonia 
which  do  not  show  early  and  well-marked  signs  of  pulmonary  solidifi- 
cation are  very  a])t  to  begin  with  several  days  of  gastro-intcslinal  symp- 
toms, the  significance  of  which  would  be  very  obscure  but  for  tlieir 
association  with  fever  and  lcukocytf)sis. 

Outcome. — Rusty,  tenacious  s])utum  was  later  raised,  and  in  it 
the  ])nciuri(x:occus  was  the  j)red()minating  organism. 

At  no  time  were  the  signs  in  the  chest  any  more  definite  than  at  en- 
trance. On  the  twenty-sixth  there  were  moist  rales  in  \-arious  ])arts 
of  tlie  lungs,  and  the  ])atient  was  somewhat  delirious.  On  tlie  thirty- 
first,  the  dav  after  the  crisis,  tliere  was  a  friction-rub  in  tlie  sixth  left 
s])ace,  anterior  axillary  line. 

On  the  twelfth  of  February  the  ])atient  left  the  h()S])ital  perfectly 
well. 

The  treatment  consisted  of  laxatives,  a  tight  swatlie,  ice  bag.  ami 
hot-water  1)ottle  for  pain,  and  an  occasional  dose  of  niori)hin. 

Diagnosis.     Pneumonia. 


292  DIFFERENTIAL    DIAGNOSIS 

Case  144 

An  Italian  farm-laborer,  sixty-six  years  old,  was  first  seen  Januar\' 
30,  1908.  His  family  history  and  past  history  were  negative,  his  habits 
good.  Seventy-two  hours  ago,  while  standing  on  a  chair  to  put  a  cloth 
over  his  canary's  cage,  he  lost  his  balance  and  fell  to  the  floor,  striking 
his  left  side  on  the  back  of  the  chair.  He  was  unconscious  for  some 
minutes,  and  later  experienced  a  sharp  pain  in  the  left  side  of  the  chest, 
worse  on  coughing  or  deep  breathing.  This  |)ain  has  troubled  him 
ever  since,  and  has  been  accompanied  by  a  slight  dry  cough.  For  two 
days  he  has  been  feverish. 

At  entrance,  the  patient's  temperature  was  99.4°  F.;  pulse,  79;  res- 
piration, 20.  There  was  a  marked  posterior  convexity  of  the  lower 
dorsal  and  upper  lumbar  spine.  The  breath  was  foul.  There  was  a 
slight,  diffuse,  systolic  pulsation  under  each  clavicle,  especially  on  the 
left.  The  heart  was  negative.  Scattered  throughout  both  lungs  were 
sc[ueaks  and  crackles.  There  was  marked  tenderness  over  the  eighth 
and  ninth  left  rib  in  the  midaxillary  line.  Pressure  over  the  vertebral 
end  of  the  ninth  rib  caused  pain  over  the  same  rib  in  the  midaxilla.  No 
definite  crepitus  was  obtained.  A  rough  grating  was  heard  with  inspira- 
tion in  the  painful  area.  At  the  top  of  the  left  axilla  was  a  suggestion 
of  bronchial  breathing.  On  the  left  forefinger  and  the  back  of  the  last 
phalanx  was  a  raised,  reddened,  tender  area,  half  an  inch  in  diameter, 
crusted  in  the  center.  From  this  a  little  seropurulent  fluid  could  be 
expressed.  He  has  had  this  trouble  for  a  month.  The  next  day  the 
fluid  in  this  lesion  was  distinctly  purulent. 

Discussion. — Fever,  cough,  rales,  and  axillary  pain  in  a  man  of 
sixty-six  lead  straight  to  the  diagnosis  of  pneumonia  if  we  are  in  the  habit 
of  judging  by  sym])toms  alone,  and  so  far  as  the  pulmonary  signs  are 
concerned,  they  are  perfectly  consistent  with  the  existence  of  a  central 
pneumonia  or  of  ]mcumococcus  infection  which  has  not  yet  become 
localized  anywhere.  More  important  e\'idence  against  ])neumonia  is 
furnished  by  the  temperature  chart,  the  low  respiration  rate,  and  the 
absence  of  gastrointestinal  symptoms.  Up  to  the  time  when  I  saw  tlie 
jmtient  no  leukocyte  count  had  been  made,  and  as  this  seemed  to  me 
one  of  the  most  important  diagnostic  data,  I  made  the  count  at  once. 
There  were  6500  leukocytes  per  c.mm.  So  low  a  count  rarely  occurs  in 
pneumonia  unless  the  patient  is  more  ill  than  this  man  seemed  to  be. 

The  pulsations  beneath  the  clavicles  had  gi\en  rise  to  considerable 
anxiety  in  the  mind  of  the  attending  physician,  who  thought  they  might 
be  connected  with  an  aneurysm,  which  he  suspected  of  producing  ])ain 


AXILLARY    PAIN 


'■93 


in  the  side.  But  there  was  really  no  evidence  of  aneurysm,  and  the 
pulsation  was  not  greater  than  is  often  seen  in  thin  persons  whose  sub- 
clavian arteries  happen  to  lie  near  the  surface. 

Of  pleurisy  there  were  no  certain  physical  signs,  and  although  this 
diagnosis  is  often  made  on  the  basis  of  the  ])atient's  account  of  his  pain, 
and  often  definitely  at  his  suggestion,  experience  does  not  justify  anv  such 
diagnosis.  Many  patients  and  not  a  few  physicians  allow  themselves 
to  s])eak  of  "pleurisy  pains"  when  they  would  not  seriously  maintain 
that  they  had  evidence  of  any  form  of  [)leurisy.  The  rough  grating 
sound  referred  to  was  ])robably  due  to  another  cause,  soon  to  be  men- 
tioned. 

Pain  of  muscular  origin — the  so-called  yjleurodynia — akin  to  stiff 
neck  and  lumbago — must  be  shown  to  vary  directl}-  with  the  amount  of 
muscular  motion;  apparently  there  was  no  such  variation.  Pleurodynia 
j)roduces  general  widespread  tenderness,  much  less  local  than  was 
present  in  this  case. 

The  protuberance  of  dorsal  and  lumbar  \-ertebrae  makes  us  ask  whether 
an}'  form  of  spondylitis  may  be  responsible,  through  radiations  along 
ner\-e-roots,  for  this  f)atient's  jniin.  Pain  of  this  type  is  often  made  worse 
by  coughing  or  dee])  breathing.  It  does  not,  however,  lead  to  tenderness 
in  midaxilla,  and  would  be  \ery  unlikely  to  a])pear  suddenly  after  a  fall. 

The  fact  that  pressure  on  the  ninth  rilj  near  the  spine  ])roduces  ])ain 
localized  in  the  axillary  |)ortion  of  that  rib  is  strong  evidence  that  that 
rii)  is  cracked,  and  the  local  tenderness  and  the  rough  grating  sound 
following  such  a  fall  ])oint  strongly  in  the  same  direction.  In  the  ab- 
sence of  crepitus  no  further  CNidence  can  be  obtained,  unless  a  callus 
forms.  This  diagnosis  would  doubtless  have  ])een  made  at  the  start  had 
not  the  patient  chanced  to  be  feverish.  Presumably  the  fe\er  was  due  to 
the  slight  infection  on  the  forefinger. 

Outcome. — The  chest  was  stra])]:)ed  with  ])laster  and  in  two  days 
the  patient  was  well  enough  to  go  ])ack  to  work  of  a  light  character. 

Diagnosis.— Broken  rib. 

Case  145 

A  housemaid  of  twenty-five  entered  the  hospital  July  20.  i()o6. 
Xine  days  ago  she  suddenly  experienced  sharp,  shooting  i)ain  in  the  lower 
ribs  and  in  the  right  axilla,  not  worse  on  cough  nor  on  (K'ep  breathing. 
This  j)ain  lasted  one  (ia\';  she  then  began  to  ha\'e  pains  in  her  lu'ad  and 
knees,  with  fe\er.  chill,  and  general  weakness.  T'our  (la\s  ago  >hc  had 
to  gi\'e  uj)  and  go  to  bed.  Her  bowels  ha\'e  mow-d  reuularh  .  but  she 
has  \()mited  once. 


294 


DIFFERENTIAL   DIAGNOSIS 


Physical  examination  \^■as  entirely  negative. 

The  white  cells  were  2500;  no  Widal  reaction;  urine  normal,  except 
for  the  presence  of  a  diazo-reaction. 

The  course  of  the  fever  is  shown  in  the  accompanying  chart. 
Discussion. — At  the  outset  it  was  impossible  to  exclude  pneumonia, 
although  the  association  of  so  low  a  white  count  with  a  good  general 
condition   seemed  very  much  unlike   pneumonia.     Had  the  leukocyte 
count  been  high,   I   should  have  suspected  pneu- 
monia, present  or  to  come,  even  in  the  absence  of 
definite  signs  in  the  chest. 

I  have  known  a  case  altogether  similar  to  this  to 
be  counted  among  the  successes  of  a  physician  who 
thought  he  could  abort  typhoid  fever.  It  is  true 
that  typhoid  fever  not  infrequently  shows  under 
observation  no  longer  a  period  of  pyrexia  than  was 
here  recorded,  but  the  presence  of  a  diazo-reaction 
is  by  no  means  sufficient  evidence  on  which  to  base 
a  diagnosis  of  typhoid  under  these  conditions. 
Only  by  the  demonstration  of  typhoid  bacillus  or 
at  least  of  a  well-marked  Widal  reaction  can  the 
diagnosis  be  justified  when  the  fever  is  so  brief. 

Pleurisy  is  excluded  by  the  short  duration  of  the 
pain  and  by  the  absence  of  physical  signs. 

I  have  known  tertian  malaria  to  produce  symp- 
toms strikingly  like  those  with  which  this  case  ])e- 
gan,  but  the  pain  and  fever  were  then  much  more 
definitely  intermittent  and  did  not  cease  permanently  until  quinin  was 
given.     In  the  case  here  under  consideration  no  quinin  was  exhibited. 

It  is  the  fashion  to  call  such  cases  as  this  "grip"  or  ''influenza," 
but  although  these  words  are  not  taken  very  seriously  by  the  physician 
who  makes  the  diagnosis,  they  seem  to  me  sufficient  to  mislead  the  patient, 
and  incidentally  the  physician  himself.  They  hide  from  us  the  fact  that 
we  are  facing  something  which  we  do  not  understand.  A  well-known 
name  easily  transforms  itself  into  the  impression  that  we  know  some- 
thing of  the  disease  to  which  we  are  applying  it.  This  tends  to  niiike 
progress  impossible.  It  seems  more  sensible  to  recognize  that  the  un- 
named infections  are  proliably  as  numerous  as  those  already  listed  and 
named  in  our  text-books,  and  that  in  a  case  like  this  we  are  confronted 
with  one  of  this  unnamed  and  unknown  multitude. 

Outcome. — In  six  days  the  patient  seemed  perfectly  well;  the  treat- 
ment consisted  mainly  of  an  occasional  laxative  and  hypnotic. 
Diagnosis. — Unknown  infection. 


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AXILLARY   PAIN  295 

Case  146 

A  master  painter  of  sixty  entered  the  hospital  November  18,  1907. 
His  family  history  was  good.  From  the  age  of  sixteen  up  to  the  age 
of  thirty-two  he  suflfered  from  neuralgia  in  the  right  side  of  his  forehead, 
but  was  finally  cured  in  1879.  He  had  typhoid  at  eighteen,  just  after  the 
Civil  War.  Twenty  years  ago  he  was  laid  up  for  six  weeks  with  lum- 
bago, and  has  had  several  less  severe  attacks  of  this  pain  since.  He  has 
never  had  lead  colic,  nor  any  pain  in  his  joints.      His  habits  are  good. 

For  six  years  he  has  been  troubled  with  pain  in  the  left  upper  chest, 
the  attacks  gradually  growing  worse  and  more  frequent.  Now  the  pain 
is  nearly  constant  unless  he  takes  medicine.  The  pain  is  of  three  sorts: 
(i)  A  dull,  burning  pain,  present  in  the  chest  most  of  the  time;  (2)  a 
terriUy  severe  pain,  with  a  feeling  as  if  he  were  gripi)ed  in  a  vise.  This 
comes  from  once  a  week  to  once  a  month,  and  has  several  times  waked 
him  in  the  night.  (3)  A  sharp,  shooting,  knife-like  pain,  beginning  in 
his  left  chest,  running  up  to  his  shoulder  and  neck,  and  sometimes  felt 
also  in  his  arms.  This  comes  at  irregular  inter^■als — more  often  within 
the  last  two  or  three  years.  There  are  no  gastric  symptoms.  The  pain 
does  not  seem  to  have  any  relation  to  food.  There  is  no  dyspnea,  cough, 
|y<dpitation,  or  edema.  Years  ago  exertion  seemed  to  make  him  worse, 
Init  now,  he  says,  it  seems  to  make  him  better,  and  lately  he  has  dreaded 
bed-time.  He  has  been  treated  in  the  out-patient  department  since 
May,  1902.     He  still  directs  his  business  and  works  irregularly. 

Physical  examination  shows  an  obese  man,  with  normal  tempera- 
ture, j)ulse,  and  res])iration;  the  blood-pressure,  150  mm.  The  urine 
averages  40  ounces  in  twenty-four  hours;  specific  gra\ity,  1027;  no  al- 
bumin and  no  casts.  The  white  cor])uscles  range  between  12.000  and 
14,000  per  c.mm.     No  stippling  of  red  cells.     No  lead-line. 

The  tirst  sound  at  the  heart's  apex  is  followed  by  a  soft  murmur, 
l)est  heard  in  the  aortic  area,  not  transmitted  to  the  axilla.  The  aortic 
second  sound  is  greatly  accentuated.  There  is  no  demonstrable  cardiac 
enlargement.  The  pulses  are  e(|ual  and  regular,  tiie  artery  wall  not 
remarkable. 

Physical  examination  is  otherwise  negatixe,  except  that  there  is  some 
(lulness  in  the  Hanks,  which,  howe\'er,  shows  no  shift  attendant  u.iutn 
change  of  position. 

Discussion. — When  a  house-painter  complains  of  a  ]\\\n  of  ;ui\  kind, 
our  knowledge  of  the  pathologv  of  lead  poisoning  naturalK'  leads  us 
to  do  what  we  can  to  connect  the  pain  with  the  ])atieiu"s  oee;;] 'ation. 
\n  this  case,   howe\er,   there  is  no  delniite  exideiice  oi  lead  iiojsoning 


296  DIFFERENTIAL   DIAGNOSIS 

(stippling  is  often  present  in  lead-workers  who  show  no  evidence  of  ill- 
ness), and  the  pain  is  not  such  as  we  are  accustomed  to  see  produced  by 
that  disease. 

The  previous  history  of  lumbago  makes  us  seek  to  find  evidence  of 
that  disease  in  the  patient's  present  symptoms,  but  there  seems  to  be  no 
such  close  relationship  between  the  pain  and  movement  of  the  affected 
muscles  as  would  be  expected  in  lumbago. 

The  situation  and  continuity  of  the  pain  are  such  as  we  are  accustomed 
to  associate  with  aortic  aneurysm,  and  only  by  .r-ray  examination  (which 
was  not  made,  owing  to  the  patient's  poor  condition  when  he  first  entered 
the  hospital)  can  aneurysm  be  positively  excluded. 

Angina  pectoris  produces  pains  the  character  and  location  of  which 
correspond  accurately  with  those  here  described.  The  patient's  state- 
ment that  exertion  now  seems  to  make  him  better  is  practically  the  only 
consideration  that  seems  to  contradict  this  diagnosis,  and  this  is  not 
sufficient  to  exclude  it.  As  to  the  nature  and  prognosis  of  the  affection, 
our  judgment  would  be  much  assisted  if  we  knew  whether  the  patient 
was  an  excessive  consumer  of  tobacco.  No  further  certainty  can  be 
obtained  without  the  therapeutic  test  (nitroglycerin  or  amyl  nitrite)  and 
an  x-rsix  examination. 

Outcome. — He  has  used  nitroglycerin  in  doses  of  j^^  grain  from  the 
first,  and  for  years  a  single  tablet  gave  prompt  relief.  Gradually  the 
necessary  dose  has  increased,  until  of  late  he  takes  as  much  as  y^  in 
twenty-four  hours. 

A'-ray  showed  no  evidence  of  aneurysm.  During  the  patient's  stay 
in  the  hospital  he  usually  had  an  attack  each  night,  best  relieved  by 
amyl  nitrite.  Sitting  up  or  walking  about  the  ward  seemed  to  bring  on 
attacks,  relieved  in  the  same  way. 

On  the  second  of  December  he  was  discharged  not  relieved. 

Diagnosis. — Angina  pectoris. 

Case  147 

A  French-Canadian  cabinet-maker  of  thirty-six  entered  the  hos])ital 
November  3,  1906.  His  family  history  and  past  history  were  not  remark- 
able, but  he  has  used  a  great  deal  of  tobacco  and  taken  three  or  four 
drinks  of  hard  liquor  every  day  for  fifteen  years. 

Five  years  ago  he  began  to  have  pain  in  the  left  side  of  the  chest  and  in 
the  pit  of  the  stomach,  brought  on  by  exertion  or  excitement,  gradually 
increasing  in  frequency  and  in  severity.  The  pain  stabs  like  a  knife, 
lasts  about  half  a  minute,  makes  him  stop  whatever  he  is  doinc;  and  stand 


AXILLARY    PAIN  297 

bracing  himself  back.  Occasionally  it  comes  on  at  night,  and  then 
he  has  to  sit  up  in  bed  "holding  onto  himself." 

Last  winter  he  began  to  have  palpitation  and  dyspnea  on  exertion. 
Four  months  ago  he  stopped  work  by  his  physician's  advice  and  went 
into  the  country,  following  which  he  ])romptly  became  worse  and  for  a 
time  could  not  sleej)  on  less  than  four  pillows.  His  abdomen  also  swelled, 
and  the  ujjjjer  part  of  it  was  tender.  These  symptoms  ha\e  now  so 
far  subsided  that  he  can  sleep  on  one  pillow.  Two  or  three  years  ago 
his  wife  noticed  that  one  ])upil  was  larger  than  the  other.  He  has  lost 
twelve  pounds  in  the  last  three  years. 

On  physical  examination  the  above  observation  regarding  the  pupils 
was  confirmed.  Both  were  slightly  irregular  in  outline,  but  reacted 
normally.  The  heart's  impulse  was  in  the  sixth  interspace,  if  inches 
outside  the  nipple.  A  systolic  murmur  was  heard,  loudest  at  the  aj)ex, 
transmitted  also  over  the  whole  precordia  and  into  the  axilla.  In  the 
axilla  and  back,  a  harsh  diastolic  murmur  was  also  heard  replacing  the 
second  sound.  No  second  sound  at  all  was  heard  in  the  aortic  area.  The 
])ulse  was  of  the  Corrigan  type.  The  systolic  blood-pressure  was  165  mm. 
I'he  daily  amount  of  urine  averaged  30  ounces,  with  a  trace  of  albumin 
and  no  casts.  At  times  a  presystolic  rum]:)le  was  heard  at  the  a])ex. 
During  the  first  ten  days'  stay  in  the  hos])ital  he  was  given  magnesium 
sulphate,  an  ounce  every  morning,  tincture  digitalis,  10  minims  every 
six  hours,  iodid  of  ])otash  10  grains  four  times  a  day,  yIu  grain  of  nitro- 
glycerin when  needed.  His  ])rogress  during  this  period  was  uneventful. 
On  the  night  of  the  fourteenth  he  was  rather  uncomfortable.  On  the 
fifteenth  he  vomited  several  times.  His  ])ulse  was  more  rapid  and 
weaker. 

Discussion. — The  ])ain  is  strongly  suggestive  of  angina  ])ectoris,  but 
the  ])atient  seems  rather  young  for  the  organic  ty|)e,  de])endent  on  arterio- 
sclerosis, and  too  ill  for  the  functional  ty])e.  As  in  the  j)revious  case, 
we  are  unable  to  exclude  aneurysm,  as  tlie  ])atient  is  too  ill  to  be  nio\cd 
to  the  .v-ray  room.  The  pain  and  the  ine(|uality  of  the  ])upils  remind 
us  distinctly  of  that  disease. 

As  regards  the  ty])e  of  cardiac  lesion,  there  seems  to  l)e  distinct  c\  i- 
dence  of  aortic  insulTiciency  witli  liypcrtrophy  and  dilatation  ol  tlu- 
iieart.  In  a  ])atient  of  this  age  the  occurrt-ncc  of  aortic  disrasf  with  no 
preceding  rheumatic  attacks  justifies  us  in  treating  the  case  as  one  of 
sypliilis,  especiall\-  when  tlie  cardial-  lesions  are  associated  with  irreu":lar 
and  unequal  ])U])iIs.  'I'his  assumption  rests  upon  the  fact  thai  >y]iiiih's 
of  the  cardioN'ascuhir  system  usual!}"  begins  in  the  arch  of  thi-  aoria  and 
extends  thence  to  the  aortic  \al\es. 


298  DIFFERENTIAL   DIAGNOSIS 

Outcome. — x\bout  7  p.  m.  he  remarked  that  he  had  had  rather  an 
uncomfortable  day,  and  felt  that  it  was  his  duty  to  stay  in  bed,  but  that  he 
hoped  to  be  allowed  to  get  up  the  next  day.  About  8  o'clock  be  became 
unconscious  and  died  within  a  few  minutes. 

At  the  autopsy  (No.  181 6)  no  cause  for  the  suddenness  of  death  was 
discovered.  The  heart  was  greatly  dilated  and  hypertrophied.  There 
was  a  chronic  fibrous  myocarditis,  and  the  heart-wall  was  much  thinned 
near  the  apex  of  the  left  ventricle.  There  was  stenosis  of  the  coronary 
orifices  and  a  fibrous  deformity  of  the  aortic  valve.  Just  above  the  aortic 
valve,  and  in  the  arch  of  the  aorta,  were  very  many  fibrous  plaques.  A 
chronic  pleuritis  and  chronic  perihepatitis  with  adhesions  was  also 
found. 

Microscopic  examination  of  the  aortic  wall  showed  a  number  of  the 
organisms  of  syphilis  (treponema  pallidum). 

Diagnosis. — Syphilitic  heart  and  aorta. 

Case  148 

A  Jewish  laborer  of  nineteen  entered  the  hospital  November  4,  1907. 
His  family  history  and  past  history  were  good,  also  his  habits.  In  Feb- 
ruary, 1907,  he  began  to  have  a  loud,  ringing,  brassy  cough,  and  to  raise 
considerable  sputa.  At  the  same  time  he  had  hoarseness  and  pain  in 
the  left  upper  chest,  both  front  and  back.  He  improved  at  first,  later 
losing  all  he  gained.  Yet  he  has  felt  less  thoracic  pain  of  late,  although 
he  has  coughed  considerably.  Three  days  ago,  following  a  severe  par- 
oxysm of  coughing,  he  was  seized  with  intense  pain  in  the  left  lower  chest, 
both  front  and  back.  The  pain  has  gradually  improved  since,  but  is  still 
severe  on  coughing.  During  the  same  period  he  has  been  somewhat 
short  of  breath — a  new  symptom  for  him — and  has  felt  feverish. 

The  movement  of  his  temperature,  pulse,  and  respiration  is  seen  in  the 
accompanying  chart  (Fig.  48).  The  iris  of  his  left  eye  is  bluish;  of  the 
right,  brownish.  The  right  ])upil  is  smaller,  markedly  irregular,  and  situ- 
ated more  toward  the  inner  side  of  the  eye.  The  vision  of  this  eye  is  much 
diminished.  The  right  border  of  the  cardiac  dulness  extends  3I  inches 
beyond  the  midsternal  line,  and  reaches  a  point  just  inside  of  the  right 
nii)ple.  The  left  border  of  dulness  extends  about  an  inch  ])ey()nd  the 
midsternum.  Tlie  cardiac  sounds  are  best  heard  in  the  second  and 
third  right  interspaces.  Here  the  rhythm  is  fetal;  the  sounds  sharp  and 
clear.  To  the  left  of  che  sternum  they  are  difficult  to  hear.  The  left 
chest  is  hy])erresonant  throughout,  while  the  riglit  is  somewhat  dull. 
Breath-sounds  are  markedlv  diminished  on  the  left,  increased  on  the 


Fig.  49. — Physical  signs  in  Case  148.     Cough,  fever,  and  a  sudden  attack  of  pain  in  the 
lower  left  axilla  are  the  chief  complaints. 


Fig.  50. — rh\sical  signs  found  ))Osteriorl_\'  in  Case  14.S.      (See  also  Tig.  48.) 


AXILLARY    PAIN 


299 


right.  Tactile  and  vocal  fremitus  are  almost  absent  on  the  left.  Physi- 
cal examination  of  the  abdomen  and  the  rest  of  the  body  is  normal. 

By  the  seventeenth  of  November  the  patient  was  much  more  com- 
fortable, though  the  physical  signs  had  not  changed.  At  the  apex  of  the 
left  lung  a  few  fine  moist  rales  were  heard,  with  distant  bronchial  breath- 
ing and  slight  dulness  (Fig.  49). 

X-ray  revealed  a  shadow  in  the  left  chest  about  the  le\el  of  the  angle 
of  the  scapula.     There  were  evidences  of  fluid  below  this  point. 

Discussion. — Although  fever,  chest  pain,  and  cough  are  so  often  the 
precursors  of  pneumonia,  these  symptoms  have  lasted  far  too  long,  in 
the  present  case,  to  be  at  all  typical,  and  as  soon  as  we  scrutinize  the  de- 


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tails  revealed  by  physical  examination,  it  is  obvious  that  tlio  picture  is 
f|uitc  unHke  that  of  ])neumonia. 

The  extension  of  dulness,  continuous  with  that  of  the  heart's  area 
to  the  right  of  the  sternum,  the  hoarseness  and  ])rassy  cough,  and  the 
])ain  in  the  chest  suggest  aneurysm.  Hut  tlie  pain  is  on  the  left,  and  the 
extension  of  cardiac  dulness  on  the  riglU.  Tliere  are  no  pressure  siuns, 
p'.ilsations,  or  .v-rav  shadows  to  support  the  suiii)iei(Mi  ot  ani'ur_\'sin ; 
onlv  the  ])atient's  coin])laints  are  favorable  to  that  diagnosis. 

\\'hen  the  heart  is  (lisi)laced  to  tlie  right,  as  seems  to  1h'  the  case  luri', 
we  naturallv  in\-estigate  the  causes  of  this  displacement.  l)euinnin'^  with 
the  commonest  -left  jileural  cfTusion.  In  fa\'or  of  this  condition  we  ha\e 
the  dimiiuition  of  res])iratory  nuirmur  and  tht' al)Sence  ot  xocal  and  tactile 


300  DIFFERENTIAL   DIAGNOSIS 

fremitus  in  the  left  chest.  But  in  spite  of  these  signs,  pleural  effusion, 
serous  or  purulent,  may  be  unconditionally  excluded  on  the  evidence  of 
a  single  sign,  viz.,  the  hyperresonance  of  the  whole  left  chest.  Hyper- 
resonance  of  a  portion  of  one  chest — for  example,  the  lower  axillary 
region  or  the  upper  quarter — is  quite  consistent  with  pleural  effusion, 
but  total  hyperresonance  has  never  been  recorded,  so  far  as  I  know, 
with  pleural  effusion.  0\'er  a  pneumonic  consolidation  situated  deeply 
in  the  lung  substance  the  percussion-note  is  not  infrequently  hy]jerres- 
onant  or  tympanitic,  but  this  never  occurs,  I  believe,  throughout  a  chest 
containing  a  pleural  effusion.  Hyperresonance  of  one  chest  then,  with 
displacement  of  the  heart  toward  the  opposite  side,  is  practically  distinc- 
ti\"e  of  pneumothorax,  which  seems  the  reasonable  diagnosis  of  this 
case. 

Emphysema  produces  general  hyperresonance,  but  it  is  ne\"er  uni- 
lateral, never  dislocates  the  heart,  and  never  causes  pain. 

The  prolonged  cough,  with  the  rales  and  dulness  at  the  apex  of  the 
left  lung,  are  presumably  due  to  that  disease  which  almost  in\ariably 
underlies  pneumothorax — phthisis.  The  .v-ray  shadow  and  the  evi- 
dences of  fluid  which  gradually  developed  at  the  base  of  the  left  chest  are 
doubtless  due  to  the  accumulation  of  an  exudate,  converting  the  jmeu- 
mothorax  into  hydropneumothorax  according  to  the  ordinary  rule. 

Some  account  of  the  two  main  clinical  types  of  pneumothorax  has 
already  been  given.     Hence  nothing  further  is  added  here. 

Outcome. — The  sputum  contained  many  tubercle  bacilli.  A  suc- 
cussion  splash  was  once  made  out. 

On  the  nineteenth  of  December  there  was  still  no  change  in  the  ]m- 
tient's  condition  so  far  as  the  signs  in  the  chest  were  concerned;  the 
patient  was  feeling  much  better,  had  gained  considerably  in  weight,  and 
had  almost  no  cough.  On  the  twenty-lirst  of  December  he  was  allowed 
to  go  home. 

Diagnosis. — Pneumothorax  (pulmonary  tuberculosis). 

Case  149 

A  teamster  of  fifty-two  entered  the  hos])ital  April  3,  igo8.  His 
family  history  and  habits  were  good.  He  had  right-sided  pleurisy  in 
1872,  and  was  in  bed  ten  weeks  with  fever  and  pain  in  the  chest.  He 
was  not  tapped.  Since  then  he  has  been  well.  In  Octol^er,  igo;,  he 
was  struck  on  the  right  chest  l)y  a  roll  of  cotton  duck  weighing  400  ])ounds. 
He  had  some  pain  there,  which  went  off  after  a  few  days.  He  tliinks 
no  ril:)S  were  broken.  Three  weeks  ago  he  began  to  have  dull,  constant 
pain  in  the  right  cliest,  worse  on  deep  breathing.    This  })ain  lasted  a  week. 


AXILLARY    PAIN 


301 


March  30th  he  went  to  work,  but  the  pain  soon  returned  and  compelled 
him  to  stop  work.  Now  that  he  is  in  bed  he  has  practically  no  pain,  no 
cough,  no  fever,  an  excellent  appetite,  and  feels  in  most  res[)ects  very 
well. 

His  temperature,  pulse,  and  respiration  are  normal,  likewise  his 
blood  and  urine.  He  lies  comfortably  in  bed  without  dyspnea.  His 
heart  is  negative.  The  artery  walls  are  tortuous,  with  visible  pulsation 
in  the  radials,  brachials,  and  axillaries.  The  right  chest  is  flat  below  the 
fourth  rib  in  front  and  midscapula  behind.  Over  this  area  respiration 
js_absent,  likewise  voice  and  fremitus. 

Discussion. — As  this  patient  has  previously  had  i^leurisy  on  the  right 
side,  we  need  to  consider  whether  the  organized  results  of  that  attack — 
pleural  adhesions — might  account  for  the  symptoms  which  are  now 
])resent.  I  should  say  decidedly  not.  An  inflammation  which  has  en- 
tirely died  out  thirty-six  years  earlier  does  not  lead  to  acute  pain.  The 
pain  of  a  pleural  effusion  may  linger  on  for  months,  or  even  for  a  year  or 
two,  but  never  for  thirty-six  years.  Pleural  adhesions  may  cause  dul- 
ness  and  diminished  breathing,  but  not  flatness  and  absent  breathing. 

Can  the  trauma  of  October,  1907,  be  the  cause  of  the  ])resent  trouljle? 
The  inter\al  of  Ave  months  between  the  time  of  the  ]:)low  and  the  onset 
of  the  i^resent  pain  makes  this  rather  unlikely.  Hemothorax  ne\er 
results,  so  far  as  I  know,  from  an  injury  of  this  kind  without  fracture  of  a 
rib  or  ])uncture  of  the  ])leura.  Serous  ])leurisy  has  also,  in  my  opinion, 
no  connection  with  such  an  accident. 

Dro])sical  effusions  due  to  disease  of  the  heart  or  kidney  ha\e  a 
predilection  for  the  right  chest,  but  we  have  no  e\idcnce  of  any  such 
disease  in  the  present  case,  although  there  ap])ears  to  be  some  arterio- 
sclerosis in  the  peri])heral  vessels.  Further,  dro})sical  effusions  do  not 
produce  y)ain. 

Htcsc  altcrnati\es  can  be  easily  excluded,  and  the  diagnosis  of  pleural 
effusion  is  then  so  automatic  that  it  may  be  fjucstioned  whether  1  am 
juslilk'd  in  introducing  this  case  in  a  book  su])])osed  to  deal  with  diag- 
nostic difliculties.  On  this  point  1  can  only  say  that  I  have  re])eatedly 
seen  in  consultation  cases  of  serous  |)leurisy  which  had  not  ])re\iously 
i)een  recognized  because  the  ))atient  liad  com])laine(l  so  little  of  the  chest 
that  no  thorough  physical  examination  had  been  made.  I'nder  the>e  ton^ 
ditions  the  diagnosis  is  usually  "  ty])li()i(l.'"  "slow  fe\"er/'  "  autointoxiea- 
tion.''  or  "  ])tomain-])()isoning." 

It  is  worth  while  to  note  in  ])assing  that  this  patient  \\a-  in  tied 
ten  wt'eks  with  his  untap])ed  pleurisy  of  1S72,  wlierea>  in  njoS  hi--  ilines- 
lasted  less  than  two  weeks. 


302  DIFFERENTIAL   DIAGNOSIS 

Outcome. — A  paravertebral  triangle  was  demonstrated,  its  dulness 
3  inches  wide  at  the  base.  The  right  chest  was  tapped,  and  32  ounces  of 
fluid  obtained.  Specific  gravity,  1017;  albumin,  2.7  per  cent.;  lympho- 
cytes, 87  per  cent. 

The  fluid  did  not  reaccumulate.  On  April  9th  he  was  discharged 
wtII,  with  the  caution  that  he  must  always  be  rather  more  careful  than 
other  men  as  regards  fresh  air  (day  and  night),  regular  meals,  and  the 
avoidance  of  all  excesses. 

Diagnosis. — Pleural  effusion. 

Case  150 

An  Italian  housewife  of  thirty-five  entered  the  hospital  April  25, 
1907.  Three  years  ago  she  had  an  operation,  following  which  she  has 
had  no  menstruation,  but  frequent  "hot  flushes"  rising  from  the  ab- 
domen to  the  head,  accompanied  by  sweating  and  headaches  which 
sometimes  "made  her  crazy."  During  the  past  five  months  she  has  had 
frequent  attacks  of  pain  in  the  epigastrium  and  left  chest.  The  pain  is 
never  severe  enough  to  make  her  lie  down.  It  lasts  sometimes  most  of  the 
day.  It  sometimes  runs  down  the  inner  side  of  the  left  arm  to  the  finger- 
tips. The  pain  comes  on  suddenly,  feels  like  needles  pricking  the  skin, 
and  is  often  accompanied  by  a  sensation  of  heat  all  over  her  abdomen. 
Her  urine  scalds  her  during  micturition. 

She  has  worked  up  to  the  time  of  entrance,  although  she  eats  and 
sleeps  poorly  and  her  bowels  are  costive. 

Temperature,  pulse,  and  respiration  are  normal.  Physical  exam- 
ination of  the  chest  and  abdomen  is  wholly  negative.  There  is  a  thin, 
yellowish,  vaginal  discharge.     The  urine  shows  considerable  pus. 

Discussion. — Everything  inclines  us  to  explain  many  of  the  symp- 
toms in  this  case  as  the  result  of  an  artificial  menopause.  We  must  make 
sure,  however,  tliat  the  familiar  and  typical  phraseology  used  by  such  a 
])atient  does  not  sometimes  mislead  us  into  overlooking  some  deeper 
organic  disease,  such  as  pulmonary  tuberculosis.  If  this  occurs  to  us 
as  a  possibility,  the  use  of  a  thermometer  will  soon  make  clear  in  the 
vast  majority  of  cases  that  there  is  no  fever,  the  sweating  and  sense  of 
heat  being  due  to  vasomotor  changes. 

The  presence  of  pus  in  the  urine  makes  it  reasonal)le  to  inquire 
whether  some  local  infection  of  the  genito-urinary  tract  may  not  l)e  con- 
nected with  the  cardiac  symptoms,  since  gonorrheal  endocarditis  is  not 
nearly  so  rare  as  is  often  supposed.  The  first  point,  however,  is  to  make 
sure  that  we  are  dealing  with  a  genuine  jnuria,  not  with  an  admixture 
of  urine  and  vaginal  discharge.     In  the  present  case  a  s])ecimen  of  urine 


AXILLARY    PAIN 


3^3 


drawn  by  catheter  showed  no  pus.  A  smear  from  the  vaginal  discharge 
showed  a  variety  of  saprophytic  organisms,  but  no  gonococci. 

Returning  now  to  the  main  complaint — the  thoracic  and  epigastric 
pain — we  notice  first  that  it  is  accompanied  by  paresthesia,',  that  it  has 
no  special  relation  to  exertion,  and  is  often  prolonged  over  many  hours. 
These  facts,  together  with  the  negative  results  of  ])hysical  examination, 
tend  to  show  that  it  is  not  due  to  the  organic  type  of  angina  pectoris,  but 
belongs  in  the  loose  group  of  pains  to  which  the  name  of  "functional" 
or  "false"  angina  has  been  given.  As  in  so  many  other  cases  of  this 
group,  the  patient's  own  interpretation  of  the  pain  have  led  to  forebod- 
ings and  apprehensions,  and  so  to  a  concentration  of  attention  which 
greatly  increases  the  suffering.  The  clinical  importance  of  this  fact  is 
that  it  should  lead  us  to  a  much  greater  vehemence,  directness,  and  cir- 
cumstantiality in  our  reassurances  than  would  seem  to  l)e  warranted 
by  the  patient's  own  statement.  The  organic  effects  of  a  fear  are  often 
in  proportion  to  the  patient's  reticence  upon  the  subject. 

Outconie. — After  eloquent  reassurance  and  a  few  days'  rest  with  full 
diet  the  patient  seemed  so  much  better  that  she  was  allowed  to  go  home. 

Diagnosis. — Artificial  menopause. 

Case  151 

A  Portuguese  lumberman  of  forty  entered  the  hospital  May  30.  1908. 
His  family  history,  past  history,  and  habits  ha\'e  been  good.  Three 
years  ago  he  began  to  have  [)ain  in  the  left  side  of  the  chest,  with  cough 
and  thick  yellow  sputa;  also  a  headache,  backache,  lack  of  a])})etite, 
occasional  vomiting.  For  the  past  week  he  has  been  worse.  Three 
days  ago  he  took  to  bed.  His  throat  is  now  rather  sore.  The  course  of 
the  temperature,  j)ulse,  and  res])iration  is  seen  in  the  accom])an\ing 
chart  (iMg.  51 ). 

The  patient  was  found  to  be  slightly  delirious,  with  rapid  res- 
piration and  slight  dry  cough.  The  leukocytes  were  5000  per  c.nim. 
the  urine,  negati\e.  ^\'idal  reaction  negati\e.  l"he  heart  was  negative. 
There  were  coarse  rfdes  scattered  throughout  both  chests.  In  the  left 
back,  just  outside  the  lower  end  of  the  scapula,  the  voire  sounds  were 
siightlv  nasal.  The  right  chixicle  was  somewhat  more  i>rominent  than 
the  left,  and  ex{)iration  just  below  it  was  somewhat  prolongefk  The 
abdomen  was  lield  rather  rigidlw  and  there  was  slight  general  tender- 
ness there.     The  spleen  was  not  t\-h.  and  there  were  no  rose  s]m)1>. 

Discussion. — A  low  leukoc\t(^  count  in  a  patient  who  i>  not  ap- 
])arentl\-  \-er\'  ill  may  be  taken  as  im])ortant  e\idence  aL'aiii>t  the  diag- 


304 


DIFFERENTIAL   DIAGNOSIS 


nosis  of  pneumonia,  especially  if  the  patient's  lungs  give  little  evidence 
of  disease. 

Pulmonary  tuberculosis  seems  more  probable  in  view  of  the  long 
duration  of  cough  with  sputa,  but  unless  we  suppose  that  we  are  dealing 
with  a  miliary  tuberculosis,  there  is  not  enough  in  the  lungs  to  account 
for  so  sudden  and  severe  an  illness.  Miliary  tuberculosis  cannot  be  ex- 
cluded. The  evidence  is  suggestive,  but  not  compelling.  This  possibil- 
ity should,  therefore,  be  held  in  reser\'e  until  other  alternati^•es  are  ex- 
hausted. 

Acute  influenzal  bronchitis,  or  bronchitis  of  some  other  type,  might 
account  for  most  of  the  facts  in  this  case.     This  diagnosis  also  it  is  im- 


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possible  to  exclude,  although  my  im|)ression  as  I  saw  the  natient  was  that 
he  was  too  sick  for  simple  bronchitis.  The  grounds  of  this  im])ression. 
however,  are  hard  to  convey.  Bronchitis  and  miliary  tu])erculosis,  there- 
fore, remained  as  possibilities  to  be  acce})ted  or  rejected  as  the  further 
course  of  the  case  might  determine. 

Influenzal  infection  of  numerous  small  Ijronchiectases  1  such  as  occur 
very  frequently  with  the  clinical  ])icture  of  chronic  winter  cough)  is 
strongly  suggested  ])y  the  history  and  is  compatible  with  the  physical 
sign  here  described.  It  rarely  causes  so  high  a  temperature,  however, 
usually  produces  leukocvtosis  with  jirofuse  nummular  s])uta,  and  often 
has  an  emi)hvsema  associated  with  it. 


AXILLARY   PAIN 


305 


Meantime  it  is  important  not  to  forget  the  possibility  of  typhoid 
fever,  although  the  time  of  the  year  is  not  the  usual  one,  and  although 
no  definite  evidence  of  typhoid  has  yet  been  presented.  It  seems  to  me 
essential,  however,  that  we  should  consider  typhoid  in  every  febrile 
patient  with  vague  and  colorless  symptoms  which  do  not  compel  us  to 
incriminate  any  one  organ  or  group  of  organs.  Typhoid  is,  beyond  all 
other  infections,  tlie  disease  which  produces  fever  with  nothing  particular 
to  show  for  it  in  the  way  of  local  lesions.  Hence  in  all  such  cases  we 
should  remember  it  and  test  for  it  by  all  the  available  methods. 

Outcome. — Blood-culture  taken  into  bile  was  positive  for  typhoid 
bacilli. 

The  course  of  the  disease  was  uneventful.  The  patient  went  home 
well  on  the  thirteenth  of  July.  There  was  but  little  cough  or  sputa. 
The  treatment  consisted  of  \  grain  of  calomel  given  every  fifteen  minutes 
for  ten  doses,  at  the  time  of  entrance,  followed  by  a  suds  enema;  there- 
after he  had  alcohol  and  water  sponges  at  80°  F.  every  four  hours  when 
the  temperature  was  above  102.5°  F.;  urotropin,  7  grains,  three  times  a 
day  twice  a  week,  and  turpentine  stupes  from  time  to  time.  In  conva- 
lescence he  had  a  good  many  boils,  from  one  of  which  the  staphylococcus 
was  isolated.     For  this,  staphylococcus  vaccine  was  given. 

Diagnosis.— Typhoid. 

Case  152 

A  Turkish  rug-repairer  of  forty-seven  entered  the  hospital  May  2, 
1908,  stating  that  when  he  was  twenty-six  he  was  sick  for  three  weeks, 
and  had  shortness  of  breath  on  exertion.  He  has  since  been  well  until 
three  weeks  ago,  when  lie  began  to  have  pain  in  the  back  of  his  neck  and 
the  left  side  of  his  chest,  with  dyspnea,  orthopnea,  and  nocturia.  For 
ten  days  he  has  had  cough  and  yellowish  sputa. 

The  patient's  tem|)erature  during  the  nine  weeks  of  his  stay  in  the 
hospital  was  generally  su!)normal;  his  ])ulse  averaged  about  100,  his 
rcs])iration  27.  The  daily  amount  of  urine  was  generally  diminished, 
averaging  25  ounces;  sj)ccific  gravity,  1023;  no  albumin  or  casts  were 
found. 

The  heart's  imj)ulse  was  ])cst  seen  and  felt  in  the  third  space,  four 

inches  to  the  left  of  the  midsternal  line;  the  right  border  one  inch  to  the 

right  of  the  median  line.     In  the  fourth  s])ace  tiie  impulse  was  barely 

felt.     The   sounds   were   loudest   and    the   ]xdpa])le   im])ulse    strongest 

just  below  the  cnsiform.     The  sounds  were  regular  and  of  good  (lualit}'. 

the  pulmonic  second  accentuated.     The  jnilse  was  of  good  xolume  and 

tension.     In  front  the  percussion-note  was  dull  below  the  left  fourth  rib, 
20 


3o6  DIFFERENTIAL  DIAGNOSIS 

below  the  fifth  rib  on  the  right,  below  the  angle  of  the  left  scapula,  while 
in  the  right  back  the  dulness  extended  one  inch  higher.  Over  these  dull 
areas  breathing,  vocal  and  tactile  fremitus  were  diminished.  There  were 
many  fine,  crackling  rales  at  the  left  base,  and  a  few  coarse  crackles  after 
cough  at  the  left  top,  behind.     The  systolic  blood-pressure  was  145. 

The  spleen  was  easily  palpable.  The  abdomen  and  extremities 
otherwise  negative. 

On  the  night  of  the  fourth  of  May  the  patient's  respiration  became 
rapid  and  difficult — respiration,  42,  with  pulse,  130;  tracheal  rales  could 
be  heard  half-way  across  the  ward.  The  first  heart-sound  was  almost 
inaudible,  the  second  loudly  accentuated.  The  pulse  was  very  weak. 
The  outline  of  the  heart  was  normal  on  percussion.  The  patient  was 
livid,  cyanotic,  and  covered  with  perspiration. 

Discussion. — But  for  the  persistently  subnormal  temperature  coming 
on,  as  it  has,  with  acute  axillary  pain  and  dyspnea,  one  might  think  of 
pneumonia  in  this  case,  although  the  duration  is  somewhat  too  great. 
The  signs  in  the  lungs  point  to  fluid  accumulation  in  both  chests. 
Is  this  an  exudate  or  a  transudate,  due  to.  inflammation  or  to  dropsy? 
Double  pleural  effusion  is  very  rare.  The  absence  of  fever  and  of  pain 
connected  with  respiration  makes  pleural  effusion  still  more  unlikely. 
Indeed,  this  possibility  would  scarcely  have  been  considered  but  for  the 
fact  that  there  seems  hardly  enough  in  the  condition  of  the  heart  or  kidney 
adequately  to  account  for  so  much  effusion  as  a  dropsy. 

In  the  urine  there  is  really  no  evidence  of  renal  disease,  the  slight 
variations  from  normal  being  more  characteristic  of  passive  congestion. 
In  the  heart,  accentuation  of  the  pulmonic  second  sound  is  the  chief 
abnormality,  and  this  is  indicative  less  of  any  cardiac  lesion  than  of  a 
blocked  condition  of  the  lungs,  however  produced.  The  displacement 
of  the  apex  impulse  is  also  to  be  regarded  rather  as  the  result  of  the 
pleural  effusion  than  of  any  disease  of  the  heart  itself.  On  the  whole, 
therefore,  there  is  no  direct  evidence  of  heart  disease  obtainable  by  ex- 
amination of  the  organ  itself,  and  if  we  are  to  predicate  any  weakness  of 
the  heart's  action,  we  must  do  so  upon  the  evidence  of  passive  con- 
gestion in  the  pulmonary  circuit.  Tliis  is  not  satisfactory,  but  it  is 
a  very  familiar  dilemma,  and  one  in  which  experience  has  shown  that  it 
is  usually  safe  to  assume  a  myocardial  lesion  provided  that  there  is  no 
evidence  of  nephritis,  goiter,  or  adherent  pericardium.  Such  diagnoses 
as  "myocarditis"  used  to  be  much  more  frequent  than  they  are  at  the 
present  day,  since  the  habit  of  routine  blood-pressure  measurements  has 
led  us  to  recognize  so  many  latent  cases  of  chronic  nephritis  not  evident , 
by  urinary  examination.     In  the  present  case  it  seems  inevitable  that  we 


AXILLARY   PAIN 


307 


should  blame  the  heart-wall  for  the  circulatory  disturbance,  though  it 
may  be  wiser  to  speak  of  ''myocardial  weakness"  (adopting  the  vaguer 
functional  term),  rather  than  of  "myocarditis." 

The  acute  attack  of  May  4th  tends  to  confirm  our  opinion  that  the 
heart  is  organically  weak.  This  attack  will  be  easily  recognized  as  one 
of  acute  pulmonary  edema — one  of  the  most  interesting  and  mysterious 
of  clinical  pictures.  The  vast  majority  of  such  attacks  occur  in  persons 
whose  cardiovascular  system  has  shown  a  distinct  but  not  extreme  grade 
of  degeneration  and  weakness.  In  many  cases  the  kidney  has  also  shown 
evidence  of  chronic  disease,  but  this  is  about  the  sum  of  our  knowledge 
on  the  subject.  As  to  the  nature  and  determining  cause  of  the  attacks, 
we  know  almost  nothing,  and  in  a  few  cases  we  are  not  even  warned  or 
guided  by  any  definite  evidence  of  cardiac  or  renal  disease;  the  edema 
appears,  as  it  were,  out  of  a  clear  sky.  It  will  be  understood,  of  course, 
that  the  types  of  edema  here  briefly  referred  to  are  distinguished  from 
the  ordinary,  long-standing,  gradually  increasing  edema  of  uncompen- 
sated heart  disease. 

Outcome. — He  was  bled  a  pint  from  a  vein  of  the  left  arm  and  given 
strychnin,  -^  grain,  and  digitalone,  20  minims,  subcutaneously.  Fol- 
lowing this  the  pulse-rate  fell  at  once  to  ico,  and  the  perspiration  and 
dyspnea  diminished.  The  left  chest  was  then  tapped,  and  three  pints 
of  fluid  removed.  After  this  the  pulse  fell  to  90.  After  I  grain  morphin 
subcutaneously  the  patient  went  at  once  to  sleep  and  slept  five  hours, 
waking  vastly  improved,  with  good  color,  strong  and  regular  heart 
action. 

The  fluid  removed  from  the  chest  had  a  gravity  of  loii,  with  2.7  jjcr 
cent,  albumin.  In  the  sediment  lymphocytes  made  up  76  ])er  cent., 
polynuclears,  14  per  cent.,  endothelial  cells,  10  per  cent. 

Two  nights  after  this  he  again  became  uncomfortable;  the  other 
chest  was  as])irated  and  four  pints  of  fluid  withdrawn.  The  sj)eciric 
gravity  was  again  ion;  the  albumin  only  1.2  ])er  cent.;  lymphocytes, 
77  per  cent.  The  j)atient  was  then  given  magnesium  sul])hate  ]  ounce 
every  morning,  a  dram  of  PVench  \'ermouth  in  a  small  amount  of  water 
just  before  dinner  and  supper,  diuretin.  15  grains  four  times  a  day. 
FoHowing  the  ta])i)ing  of  tlie  chest  the  amount  of  urine  increased  markedl}'. 
On  the  sixth  of  July  he  left  the  hos])ital  much  reHc\e(l. 

Diagnosis. — Weak  heart;  acute  pulmonary  edema. 

Case  153 

A  single  woman  of  twcnty-fix-e,  a  nurse,  entered  the  ward  on  January 
2,  1906.     The  night  before  she  had  had  some  ])ain  in  the  left  side.     She 


3o8 


DIFFERENTIAL  DIAGNOSIS 


was  awakened  by  it  several  times  in  the  night.  She  finds  it  uncomfortable 
to  lie  on  the  right  side  or  on  the  back,  but  pressure  on  the  left  side,  or 
lying  on  that  side,  relieves  the  pain.  She  has  an  extremely  tender  spot 
under  the  right  border  of  the  ribs  in  front. 

Examination  showed  spasm  in  the  right  hypochondrium,  with  tender- 
ness.   The  pain,  however,  was  consistently  referred  across  the  abdomen  to 
a  point  in  the  left  axilla  on  a  level  with  the  lejt  nipple.    Physical  examina- 
tion, including  blood  and  urine,  was  otherwise  negative.    The  temperature 
ranged  between  99°  and  101°  F.     The  pain  did  not 
seem  to  be  affected  by  morphin,  and  came  on  two  or 
three  times  a  day  in  spasms  lasting  one-quarter  to 
one-half  hour.     The  tender  point  in  the  right  upper 
quadrant  grew  steadily  more  rigid  and  more  sensitive. 
Pressure  there  caused  pain  to  shoot  to  the  left  axilla. 
She  was  seen  daily  by  a  surgical  consultant,  who  did 
not  advise  operation.     On  the  fourth  day  the  white 
cells  rose  to  14,000. 

Discussion. — This  case  is  introduced  to  exemplify 
an  unusual  reference  of  pain  to  a  point  far  removed 
from  the  lesion  producing  it.  The  tenderness  and 
spasm  turn  out  here,  as  in  so  many  other  cases,  to 
guide  us  better  than  the  pain,  when  the  two  diverge. 
A  rhythmic  or  spasmodic  character  in  any  painful 
seizure  usually  turns  out  to  mean  frustrated  peristalsis 
within  a  hollow  muscular  organ.  But  there  is  no  such 
organ  in  the  left  axilla;  the  nearest  hollow  muscular 
organ  is  the  heart,  and  there  is  nothing  else  in  the 
clinical  picture  to  connect  the  pain  with  that  organ. 
The  rising  leukocyte  count  and  the  fever  are  data  not  ordinarily 
associated  with  angina  of  any  type. 

Outcome. — Three  days  later  the  abdomen  was  opened  and  a  much 
distended  and  twisted  gall-bladder  found;  the  cystic  duct  was  dilated, 
twisted,  and  occluded  by  a  large  stone.     Three  other  stones  were  also 
found  in  the  gall-bladder,  which  was  acutely  inflamed. 
Diagnosis. — Gall-stones. 


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of  case  153. 


Case  154 

A  Swedish  machinist  aged  twenty-five  entered  the  ward  February  8, 
1907.  Five  weeks  previously  he  had  suffered  from  tonsillitis.  In  two 
weeks  he  was  back  at  work,  but  began  to  have  pains  in  his  legs  and  feet; 
at  one  time  both  knees  were  red  and  swollen.     Ten  days  ago  he  gave 


AXILLARY   PAIN 


309 


up  work  and  went  to  bed,  with  fever,  headache,  loss  of  appetite,  and 
weakness.  His  chief  complaint  for  the  past  week  has  been  pain  in  both 
chests,  worse  in  the  right  front.  His  legs  have  shown  only  indefinite 
stiffness  and  soreness  in  the  past  few  days. 

Physical  examination  of  the  chest  showed  in  the  right  axilla  very 
slight  dulness,  with  diminished  breath-sounds  and  a  suggestion  of  friction. 
The  heart  was  negative.  There  was  no  redness  or  swelling  of  any  joint, 
but  some  pain  on  motion  of  the  right  knee,  and  a  slight  rigidity  of  the 
neck.  Belly  negative.  Temperature,  101.8°  F. ;  pulse,  120;  respiration, 
30;  hemoglobin,  70  per  cent.;  white  cells,  24,000;  urine  normal. 

On  the  twelfth  of  February  there  was  still  no  evidence  of  any  localiza- 
tion of  the  infection  except  that  the  signs  in  the  lower  right  axilla  had 
slightly  increased.  The  patient  looked  decidedly  sick,  and  the  white 
count  had  risen  to  25,400.  On  the  fourteenth,  pain  and  edema  of  the 
whole  right  leg  appeared  without  tenderness;  the  next  day  swelling  ap- 
peared in  the  left  foot  and  the  veins  below  the  left  knee  were  distended; 
there  were  still  no  tenderness  and  no  change  in  the  signs  in  the  right  chest. 
By  the  sixteenth  the  swelling  of  the  left  leg  had  considerably  increased, 
and  there  was  tenderness  over  the  red,  cord-like  veins  of  the  left  calf. 
The  white  count  remained  the  same,  88  per  cent,  of  the  cells  being  poly- 
nuclear. 

The  patient  remained  in  the  hospital  until  August  12th — six  months. 
There  was  some  sloughing  of  the  superficial  tissues  of  the  right  foot. 
A  well-marked  nephritis  aj)peared  on  the  twenty-fourth  of  February,  and 
lasted  until  July,  but  finally  disappeared  altogether.  Pleurisy  appeared 
in  the  left  side  on  the  tenth  of  May,  but  disappeared  in  the  course  of  a 
week.  Thrombosis  appeared  in  both  arms  in  the  early  part  of  March, 
and  in  the  middle  of  the  month  there  was  bloody  expectoration  for  a  couple 
of  days,  without  any  special  pulmonary  signs  to  account  for  it.  By 
Ai)ril  ist  the  arms  were  normal  and  the  left  leg  nearly  so. 

A  marked  anemia  gradually  developed,  so  that  on  the  thirteenth  of 
Ajjril  the  red  cells  were  2,725.000,  with  65  per  cent,  of  hem()glot)in. 
Late  in  June  there  were  purpuric  s])ots  on  the  dorsum  of  the  left  foot, 
but  tliey  (lisa))peared  within  a  few  days. 

Discussion. — As  the  history  of  this  case  opens  with  a  tonsillitis. 
it  mav  ])e  well  to  consider  some  of  tlie  lesions  which  the  clinical  experience 
of  the  last  fifteen  years  tends  to  associate  with  tonsillar  inl1ammali(Mi. 
•Mthough  the  majority  of  cases  of  tonsillitis  i^rogress  beyond  their  (nii:in 
no  further  than  the  Ivmphatic  glands  at  the  angle  (^f  the  ydw.  the  \ery 
striking  prostration  which  accompanies  and  follows  the  acute  iuteetion 
probal>ly  indicates  that  the  disease  rarely  remains  local.     It  seems  to  be 


3IO 


DIFFERENTIAL  DIAGNOSIS 


shown  beyond  reasonable  doubt  that  in  many  cases  an  infection  first  de- 
monstrable in  the  tonsil  appears  soon  after  in  one  or  another  synovial 
membrane  or  joint  surface,  in  the  endocardium,  in  the  kidney,  or  on 
some  serous  surfaces.  This  may  be  taken  to  indicate  that  bacteria  are 
circulating  in  the  blood-stream  in  a  considerable  proportion  of  cases, 
though  they  have  not  often  been  isolated  by  blood  culture. 

The  case  above  described  is  remarkable  chiefly  because  it  narrates  the 
fortunes  of  a  patient  who  suffered,  one  after  another,  most  of  the  common 
complications  of  tonsillitis  above  referred  to.  Beginning  with  multiple 
arthritis  and  right-sided  pleurisy,  he  next  suffered  a  series  of  infections 
of  the  peripheral  vein'j,  leading  to  multiple  thrombi.  Then  came  the 
nephritis,  which  I  have  often  seen  occurring  in  tonsillitis  as  the  only  mani- 
festation of  the  body's  effort  to  expel  invaders.  The  pulmonary  bleeding 
is  probably  to  be  explained  as  analogous  to  the  purpuric  spots  which 
appeared  for  a  few  days  in  the  latter  part  of  his  illness.  Only  histologic 
examination  could  decide  whether  these  pulmonary  and  cutaneous  hem- 
orrhages were  due  to  embolism  or  to  some  other  cause.  The  develop- 
ment of  a  marked  anemia  in  a  six  months'  illness  of  this  severity  is  not  to 
be  wondered  at,  since  chronic  sepsis  always  tends  to  produce  anemia. 
But  it  is  quite  remarkable  that  the  heart  escaped,  apparently  without 
injury.  Possibly  the  transient  rigidity  of  the  nen  might  be  interpreted 
as  a  larval  infection  of  the  meninges  ("meningi^mus"),  since  we  know 
that  all  the  serous  membranes — pleura,  pericardium,  peritoneum,  men- 
inges—may  be  attacked  in  cases  of  generalized  sepsis. 

Another  very  remarkable  feature  about  thij  lase  was  that  the  patient's 
final  recovery  was  complete.  The  treatment  ;onsisted  essentially  of 
good  nursing. 

Diagnosis. — Sepsis  with  thrombi. 

Case  155 

An  Italian  laborer  of  twenty-nine  entered  the  hospital  on  March  i8, 
1908.  The  family  history  was  negative;  his  past  history  likewise  so;  his 
habits  good. 

Four  weeks  ago  he  began  to  have  pain  in  his  left  chest,  chiefly  low 
down  in  the  axilla,  accompanied  and  aggravated  by  cough  or  deep 
breathing.  There  was  slight  dyspnea  on  exertion.  For  three  days  he  has 
felt  chilly  and  feverish,  especially  at  night.  He  has  noticed  nothing 
remarkable  about  his  urine,  and  no  pain  except  as  above  described. 

On  physical  examination  the  heart  showed  nothing  abnormal.  The 
right  side  of  the  chest  moved  better  than  the  left,  and  there  was  slight  dul- 
ness  at  the  right  pulmonary  apex  as  low  as  the  second  rib,  with  broncho- 


AXILLARY   PAIN 


311 


vesicular  respiration  and  increased  voice.  At  the  base  of  the  left  axilla 
the  percussion-note  was  flat  below  the  sixth  rib.  Tactile  fremitus  was 
absent,  voice-  and  breath-sounds  diminished.  Over  the  area  of  flat- 
ness were  scattered  a  few  fine  rales,  and  some  were  audible  as  high  as  the 
second  rib.  In  the  back  the  area  of  flatness  reached  up  to  the  lower  angle 
of  the  scapula.  Tactile  fremitus  was  diminished  over  the  whole  left 
back,  and  absent,  together  with  voice-  and  breath-sounds,  below  the  angle 
of  the  scapula.  A  paravertebral  triangle  was  percussed  out  on  the  op- 
posite side.  The  abdomen  showed  considerable  general  rigidity  and 
in  the  extreme  flanks  some  dulness,  which  did  not,  however,  exhibit  any 
change  with  change  of  position.  During  the  next  ten  days  his  tempera- 
ture ranged  between  99°  and  101°  F.,  his  pulse  between  70  and  80,  his 
respiration  between  20  and  25,  his  urine  between  40  and  50  ounces  in 
twenty-four  hours,  with  a  slight  trace  of  albumin,  a  moderate  amount  of 
pus,  many  hyaline  and  granular  casts,  some  of  which  have  blood  or  fat 
adherent.     The  leukocytes  were  6700;  hemoglobin,  75  per  cent. 

By  March  22d  the  dulness  in  the  chest  had  somewhat  diminished, 
and  the  paravertebral  triangle  was  not  evident.  The  dulness  on  the 
left  side  seemed  to  rise  higher  in  the  axilla  than  near  the  spinal 
column.  A  large  mass  was  now  felt  in  the  left  flank,  but  could  not  be 
definitely  outlined  on  account  of  the  rigidity  of  the  whole  abdomen,  which 
did  not  relax  even  in  a  warm  bath. 

On  the  twenty-fourth  of  IMarch  the  .r-ray  showed  apparently  a  large 
stone  in  the  left  kidney. 

On  March  27th  the  area  of  dulness  in  the  left  chest  had  not  changed, 
but  there  were  coarse,  moist  rales  in  the  right  lower  back  and  axilla. 
The  urine  still  showed  a  slight  amount  of  pus.  Cystoscopy  showed  this 
pus  to  issue  from  the  left  ureter,  while  normal  urine  came  from  the  right. 

Discussion. — The  signs  at  the  base  of  the  left  axilla  and  in  the  back 
seem  to  indicate  a  localized  pleurisy,  with  or  without  a  small  efi"usion.  In 
view  of  the  later  developments  of  the  case,  however,  I  l)clicvc  that  the  ])ara- 
vertcbral  triangle  was  percussed  out  largely  as  the  result  of  "expectant 
attention" — /.  e.,  of  the  interne's  conscientious  determination  to  find  it. 
Even  at  the  beginning  of  the  case  every  one  who  saw  the  jxitient  felt  that 
the  pleural  effusion  was  not  sufiicient  to  account  for  the  marked  fc\ei 
and  constitutional  symptoms.  We  all  thought  there  must  l)e  "  sonu'tliiug 
back  of  it." 

(^ur  first  clue  to  that  "something"  in  the  background  was  the  find- 
ing of  ])us  in  the  urine.  This  led  us  to  search  more  carefully  the  reuion 
of  the  kidneys,  whence  the  mass  in  the  left  flank  came  to  lii^ht.  As  I 
read  the  record  now  it  is  amusing  to  note  how  promptly  the  chest  signs 


312  DIFFERENTIAL   DIAGNOSIS 

retire  into  the  background  of  the  cKnical  picture  as  the  kidney  begins  to 
loom  up  in  the  foreground.  How  far  this  represents  the  actual  course  of 
events  in  the  patient  and  how  far  it  is  a  matter  of  the  historian's  psy- 
chology it  is  now  difficult  to  say. 

Outcome. — On  March  28th  operation  showed  a  large  kidney  filled 
with  thick  pus  and  adherent  to  the  diaphragm  and  other  structures. 
No  stone  was  found,  but  there  was  a  calcareous  plate  near  the  surface  of 
the  kidney;  no  histologic  report  is  preserved. 

The  patient  made  a  good  recovery. 

Diagnosis. — Pus  kidney  (tuberculous  ?). 

Case  156 

A  widow  of  forty  entered  the  hospital  February  13,  1908.  She  had 
typhoid  fever  three  years  before,  and  was  operated  on  for  extra-uterine 
pregnancy  seven  years  before.  Otherwise  she  has  ne\'er  been  sick,  but 
has  had  many  colds  this  winter.  Six  weeks  ago  she  began  to  suffer 
from  pain  in  the  left  side  of  the  chest.  Four  weeks  ago  she  had  to  give 
up  her  work  on  account  of  vomiting  immediately  after  eating.  The 
vomitus  rarely  contained  food.  It  usually  was  greenish.  There  was 
constant  soreness  in  the  epigastrium,  and  a  good  deal  of  pain  in  the  left 
arm  and  left  side  of  the  chest.  She  has  taken  almost  no  solid  food  for  sev- 
eral weeks.  She  has  considerable  dyspnea  and  palpitation,  and  has  lost 
twenty-six  pounds.  Twice  she  has  had  shivering  spells  lasting  several 
hours  at  night.  She  admitted  the  occasional  use  of  alcohol,  and  it  was 
apparent  on  her  breath  at  the  time  of  entrance.  Some  nights  she  passes 
urine  at  frequent  intervals. 

Physical  examination  was  negative  except  for  considerable  tenderness 
in  the  epigastrium  and  moderate  enlargement  of  the  axillary  glands  on 
both  sides.     Blood-pressure,  135. 

Discussion. — On  p.  738  of  this  book  I  have  referred  to  a  case 
diagnosed  and  treated  as  neurasthenia,  but  d}-ing  shortly  afterward  of 
cancer  of  the  pleura.  The  symptoms  in  that  case  were  not  unlike  those 
described  above,  and  my  remembrance  of  the  former  mistake  leads  me 
to  be  especially  cautious  in  the  diagnosis  of  supposedly  neurasthenic 
pains  in  the  side  of  the  chest.  The  presence  of  enlarged  glands  would 
be  quite  consistent  with  malignant  disease  of  the  chest,  and  is  often  one 
of  the  most  important  clues  to  the  discovery  of  that  trouble.  The  import- 
ance  of  this  enlargement,  however,  is  weakened  by  the  fact  that  it  is  bi- 
lateral. Adenitis  secondary  to  malignant  disease  is  usually  unilateral. 
In  the  present  case  I  did  my  best  to  find  signs  of  malignant  disease 
by  physical  examination  of  the  chest,  but  could  fmd  nothing. 


AXILLARY   PAIN 


3^3 


By  the  negative  results  of  physical  examination,  which  included  a 
temperature  record,  we  were  able  also  to  exclude  pleurisy. 

The  extension  of  the  pain  to  the  left  arm,  the  presence  of  dvspnea 
and  palpitation,  and  the  age  of  the  patient  are  data  quite  consistent  with 
the  diagnosis  of  angina  pectoris.  Against  this,  however,  is  the  absence 
of  any  relation  to  exertion  as  a  cause  of  pain,  the  long-standing  and 
moderate  character  of  the  suffering,  and  the  low  blood-pressure. 

After  the  exclusion  of  these  and  all  the  other  possibilities  which  we 
could  call  to  mind,  it  seemed  best  to  make  a  diagnosis  of  neurosis  and  use 
that  as  a  working  basis  for  a  therapeutic  test. 

I  interpret  the  left  axillary  pain  as  due  to  that  commonest  of  all 
causes  for  such  a  complaint,  viz.,  Jiatulence.  When  the  stomach  is  over- 
distended,  whether  by  atmospheric  air  which  has  been  swallowed  and 
"cribbed"  or  by  the  products  of  gastric  fermentation,  the  "Magen- 
hlase,^^  or  bubble,  which  is  usually  to  be  seen  near  the  cardia  by  fluoros- 
copy, swells  to  huge  dimensions,  invades  the  axillary  region,  and  often 
causes  much  discomfort.  The  patient  usually  thinks  she  has  heart  dis- 
ease; the  thought  increases  her  nervousness  and  thus  her  flatulence. 
The  vicious  circle  is  then  in  complete  working  order. 

Outcome. — The  patient  was  put  to  bed  and  given  a  diet  of  licjuids 
and  soft  solids,  with  ])araldehyd,  half  to  one  tea  spoonful,  on  two  success- 
ive nights.  Within  two  days  the  \omiting  had  ceased  and  she  felt  much 
better.  She  had  apparently  been  working  hard,  and  was  of  a  neurotic 
type,  easily  frightened  by  the  slightest  unexpected  noise  or  occurrence. 
She  was  well  enough  to  go  to  work  again  on  the  twentieth  of  February. 

Diagnosis.— Neurosis. 

Case  157 

A  Greek  waiter  of  twenty-one,  with  a  negative  family  history,  entered 
the  hos])ital  November  13,  1907,  with  the  statement  that  he  has  been 
feeling  rather  poorly  for  the  j)ast  four  months,  but  had  no  definite  sym])- 
tonis  until  three  weeks  ago,  when  he  began  to  have  frequent  severe  pains 
in  the  front  and  left  side  of  his  chest  and  a  distressing  cough  \\ith()ut  cx- 
])ectoration.  I'he  pain  and  cough  were  both  worse  at  night,  l)ut  he  lias 
been  very  comfortable  lying  Hat,  and  has  complained  of  no  shortness  of 
])reath.  He  has  been  chilly  and  fcwrisli  and  had  mucli  wrtigo  and 
frontal  headache.     During  the  ])ast  three  weeks  he  has  lost  20  ])()un(ls. 

At  entrance  the  patient  was  unable  to  lie  d()\\n  on  acccnint  of  (l\s])nea. 
The  cardiac  aj)ex  was  neither  A'isible  nor  ]>al])able.  The  area  ot  tardiac 
duhu'ss.  as  sliown  in  the  diagram,  had  a  total  width  of  i  1  '.  inthes,  tiie 
left  border  of  dulness  l)eing  ~'\  inches  to  the  left  of  ih-e  niidsternuni  in  the 


314 


DIFFERENTIAL   DIAGNOSIS 


fifth  interspace.  In  the  upper  front  of  the  right  chest  there  was  tubular 
breathing  over  the  dull  area,  and  in  the  left  back,  near  the  angle  of  the 
scapula,  all  the  signs  of  solidification  were  present.  The  abdomen  was 
everywhere  dull  except  in  the  umbilical  region  and  in  the  left  flank.  The 
patient's  temperature  was  irregularly  elevated  for  the  whole  of  his  three 
months'  stay  in  the  hospital.      (See  Fig.  53.) 

The  blood  showed  9900  white  cells  and  90  per  cent,  hemoglobin. 
The  urine  was  not  remarkable.  A  paradoxic  pulse  was  demonstrated 
on  the  fifteenth. 

Discussion. — If  we  accept  as  accurate  the  record  of  a  to-and-fro 
friction-sound  at  the  point  shown  in  the  diagram,  there  seems  no  reason 
for  doubt  that  pericarditis  is  present.  It  remains  to  discover,  if  we  can, 
whether  a  pericardial  effusion  is  present  and  by  what  other  lesions  the 
pericarditis  is  complicated. 


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The  diagnosis  between  a  pericardial  effusion  and  a  dilated  heart  is 
notoriously  difficult,  often  impossible.  In  the  present  case  we  have  no 
good  cause  for  such  a  dilatation  of  the  heart — no  valvular  or  arterial  lesion, 
no  goiter  or  chronic  nephritis,  no  history  of  beer-drinking.  The  area 
of  solidification  in  the  left  back  is,  in  all  probability,  due  to  pressure  ex- 
erted upon  the  lung  either  by  a  pericardial  effusion,  a  pleural  dropsy, 
or  a  greatly  dilated  heart.  The  latter  possibility  is  very  rarely  mentioned 
in  text-books,  but  I  have  been  conA'inced  by  postmortem  evidence  that 
a  heavy,  distended  heart  in  a  patient  who  lies  persistently  on  the  back  may 
compress  the  left  lung  so  as  to  produce  an  atelectasis  or  pseudopneumonic 
condensation  of  the  lung  similar  to  that  often  caused  by  pericardial 
effusion.  A  common  mistake  in  these  cases  is  to  suppose  that  a  lobar 
pneumonia  is  present.     Experience  has  shown  that  when  we  hear  the  signs 


I"'f^-  51.— l-atcral  limits  of  an  area  of  iicrcussioii  <iuliu-ss  found  in  Case  157. 


AXILLARY   PAIN 


315 


of  solidification  near  the  angle  of  the  left  scapula  in  the  course  of  a  case 
showing  a  greatly  dilated  heart,  with  or  without  pericardial  effusion, 
these  signs  turn  out  in  the  great  majority  of  cases  to  be  due  to  pressure 
exerted  on  the  lung  by  the  heart,  or  by  a  pericardial  or  pleural  effusion, 
and  not  to  an  exudate  in  the  lung. 

The  presence  of  a  high  continued  fever  and  the  absence  of  any  cause 
for  cardiac  dilatation  in  the  present  case  incline  me  to  believe  that 
there  is  a  pericardial  effusion.  The  long  duration  of  the  case  with- 
out any  notable  improvement  suggests  that  the  pericarditis  may  be 
tuberculous. 

The  extensive  dulness  in  the  abdomen  is  in  all  probability  due  to  fluid 
which  may  be  the  result  either  of  tuberculous  peritonitis  or  of  stasis. 
Ascites  is  especially  apt  to  accumulate  as  the  result  of  a  chronic  pericardi- 
tis which  has  gone  on  to  complete  obliteration  of  the  pericardial  sac,  but 
it  does  not  seem  probable  that  the  inflammation  has  lasted  long  enough  in 
this  case  to  bring  about  that  result.  Further  evidence  as  to  the  nature  of 
the  fluid  in  the  peritoneum  might  be  obtained  by  tapping,  for  a  dropsical 
fluid  would  probably  be  of  lower  gravity  than  one  due  to  tuberculous 
peritonitis. 

Outcome. — He  was  admitted  to  Tewksbury  Almshouse  January  22, 
1908. 

The  left  lung  continued  to  show  the  flatness  and  loss  of  \oice-sounds 
below  the  fourth  rib  in  the  axillary  line.  Sputum  was  examined  twelve 
times  and  found  negative  for  the  tubercle  bacillus.  Slight  dulness  and 
bronchial  breathing  spread  to  both  lungs. 

In  February  his  temperature  rose  daily,  going  as  high  as  103°  and 
104°  F.,  but  usually  reaching  102°  F. 

He  died  June  4,  1908.     No  autopsy. 

Diagnosis. — Pericarditis. 

Case  153 

A  night  watchman  of  forty-six  entered  the  hospital  August  24.  1906. 
He  has  been  a  hard  drinker  u])  to  eleven  months  ago.  He  had  syphilis 
twenty  years  ago.  I'or  over  two  }-cars  he  has  bet-n  troubled  l)y  a  hack- 
ing cough  without  sputa,  accompanied  In'  night-sweats  and  a  slight  ])ain 
in  the  left  side  of  the  chest.  He  has  gradually  increasing  dys])nca  on 
exertion,  Inil  can  still  lie  flat  and  witli  the  greatest  comfort  on  the  right 
side.  For  the  ]>ast  ten  months  he  has  been  having  ])ain  in  tiic  k'ti  ii]'iicr 
chest  and  ])aroxysms  of  distressing  cough.  At  times  he  losi'S  his  \-oice 
for  a  few  honrs.  but  is  never  constantly  hoarse.  Xitrogiycerin  lias  gi\en 
him   considerable  relief,   but  he  has  rattled  and  whee/.ed  all   sununer. 


31 6  DIFFERENTIAL   DIAGNOSIS 

especially  during  the  last  four  days.  He  sleeps  poorly,  has  lost  much 
weight,  and  has  no  appetite. 

The  heart's  apex  is  in  the  fifth  space,  one-half  inch  outside  the  nipple, 
the  right  border  of  dulness  two  inches  to  the  right  sternal  margin  in  the 
fourth  space.  There  is  marked  bulging  of  the  left  chest  over  the  area 
shown  in  the  accompanying  diagram,  and  considerable  pulsation  in  the 
third  and  fourth  left  spaces.  The  veins  of  the  neck  and  arms  are  dis- 
tended. Loud  groaning,  whistling  sounds  are  audible  throughout  both 
lungs.  Physical  examination  of  the  heart,  blood,  and  urine  is  otherwise 
negative  (Fig.  55). 

Discussion. — If  a  careful  physical  examination  were  made  and  duly 
meditated  on  in  this  case,  the  only  hesitation  in  diagnosis  would  be  on 
the  question  whether  aneurysm  or  malignant  disease  of  the  chest  is  the 
cause  of  the  patient's  sufferings.  In  the  absence  of  such  an  examina- 
tion, however,  I  have  known  a  case  very  similar  to  this  to  be  treated 
as  consumption  for  a  number  of  months,  the  cough,  night-sv.-eats,  emacia- 
tion, and  pain  in  the  chest  being  accepted  as  sufficient  evidence  of 
phthisis. 

In  another  case  the  wheezing  and  rattling  led  straight  to  a  diagnosis 
of  bronchial  asthma  and  to  all  sorts  of  therapeutic  attempts  based  on 
that  diagnosis. 

Returning  to  the  only  diagnostic  problem  which  ought  to  exist  in  this 
case  (aneurysm  or  malignant  disease  cf  the  chest),  I  m.ay  say  in  the  first 
place  that  in  a  considerable  number  of  cases  in  which  I  have  known  this 
discussion  to  arise,  the  outcome  hcs  always  shown  aneurysm.  In  this 
man  the  history  of  syphilis,  the  absence  of  any  glandular  enlargement,  and 
the  slow  march  of  the  symptoms,  which  apparently  have  lasted  two  years, 
all  favor  aneurysm.  The  loss  of  weight  is  perfectly  characteristic  of 
aneurysm,  and  occurs,  as  I  have  previously  shown,^  in  the  vast  majority 
of  all  cases.  I  emphasize  this  point  because  in  the  discussion  of  this 
differential  diagnosis  I  have  several  times  heard  emaciation  adduced  as 
evidence  against  aneurysm  and  in  favor  of  malignant  disease. 

Outcome. — A'-ray  showed  a  large  shadow  corresponding  to  the  area 
of  dulness.  The  mass  seemed  to  grow  and  then  to  decrease  in  size  in  the 
next  few  days,  the  pulsation  ^•arying  much  from  time  to  time  in  amount 
and  in  extent.  There  were  two  main  projecting  points — one  over  the  pre- 
cordia,  and  one  abo\e  it,  under  the  clavicle.  Sarcoma  of  the  chest-wall 
was  considered  seriously.  The  patient  died  on  the  sixteenth.  Autopsy 
showed   aneurysm   of  the   first  portion  of  the  aorta;  rupture  into  the 

1  Two  Possible  Causes  of  Kmariation  Xot  Generally  Recognized,  R.  C.  Cal>ot,  M.  D., 
Jour.  Amer.  Med.  Assoc,  March  17,  1906. 


li^;.  55. — riiy.sical  si^ns  found  in  a  ]iaticnt  \\  ho  tonipiaitu-d  of  (lys]inca,  cough,  emada- 
lioii,  nighl-swoats,  and  pain  in  tiio  chest. 


AXILLARY   PAIN  317 

pericardium;  compression  atrophy  and  bronchopneumonia  of  the  left 
lung.  The  aneurysm  was  filled  by  a  very  thick  clot  lying  in  front  of  and 
above  the  heart. 

Diagnosis. — Thoracic  aneurysm. 

Case  159 

In  March,  1898,  a  housewife  of  thirty-three  came  to  the  hospital  for 
hemoptysis,  supposedly  due  to  phthisis.  No  sign  was  found  in  the  lungs. 
In  October,  1898,  she  was  again  treated  for  pleurisy  with  effusion  and 
fistula  in  ano.  She  had  had  a  nervous  breakdown  in  1896,  and  had  been 
very  irritable  and  self-centered  since  that  time. 

In  April,  1899,  she  began  to  suffer  from  pain  in  the  right  side  of  the 
chest,  much  aggravated  by  coughing  and  laughing. 

The  urine  contained  a  trace  of  bile  and  a  good  many  leukocytes ;  other- 
wise it  was  negative,  as  were  the  blood,  temperature,  pulse,  and  respiration. 

Physical  examination,  April  23d,  was  negative  save  for  a  patch  at  the 
right  base  near  the  scapular  angle,  where  there  were  slight  dulness,  dim- 
inished voice,  respiration,  and  fremitus. 

Discussion. — Pulmonary  hemorrhage  of  any  amount — an  ounce  or 
more — means  pulmonary  tuberculosis  in  999  cases  out  of  loco,  if  disease 
of  the  heart  and  aorta  be  excluded,  as  they  easily  can  be  in  most  cases. 
The  other  traditional  causes  of  hemoptysis — disease  of  the  throat, 
vicarious  menstruation,  hemorrhagic  conditions — amount  practically 
to  nothing;  that  is,  they  are  usually  quite  obvious,  like  purpura  ha^mor- 
rhagica,  or  quite  mythical,  like  vicarious  menstiuation.  Pulmonary 
hemorrhage  due  to  distomiasis  never  occurs  in  North  America  except 
among  Japanese  immigrants. 

The  fact  that  signs  are  absent  on  examination  of  the  lungs  after 
a  hemoptysis  due  to  tuberculosis  is  entirely  according  to  rule  when 
hemoptysis  is  the  first  evidence  of  disease.  \Yc  almost  nex'er  find  an)' 
signs  of  disease  until  some  months  later;  in  many  cases  we  never  find 
them  at  all,  and  only  the  postmortem  examination  ]:)roves  tuberculosis. 

All  this,  however,  refers  to  an  event  over  a  year  old.  Is  it  not  possible 
that  her  suffering,  at  the  present  time,  is  connected  with  her  ner\"ous 
condition  and  due  to  habit  pain?  Against  this  hypothesis  we  hii\c  the 
fact  that  she  has  ])reviously  had  pleurisy  with  elTusion  and  fistula  in  ano. 
both  of  them  tuberculous  alTections  in  practically  e\ery  case.  Bearing 
these  troubles  in  mind,  we  naturally  assume  that  her  })rcsent  ])ain  is  in 
some  way  produced  by  her  old  pleurisy,  of  which  there  seems  to  ]\-  still 
some  e%idcnce  at  the  right  base.  There  are,  however,  two  other  |)(^ssil)il- 
itics  which  must  first  be  considered  l^riefiv: 


3l8  DIFFERENTIAL  DIAGNOSIS 

The  urine  contains  bile.  This  directs  our  attention  to  the  liver;  but 
enlargement  of  the  liver  upward  may  produce  in  the  right  back  all  the 
signs  here  described — signs  which,  if  interpreted  as  pleurisy,  might  be 
due  either  to  a  small  effusion  or  to  marked  pleural  thickening.  I  have 
known  abscess  of  the  liver  to  produce  exactly  these  signs,  so  that  it  was 
mistaken  for  empyema.  Against  the  possibility  of  liver  disease  there  is 
not  a  great  deal  to  be  said,  as  our  methods  for  detecting  liver  disease  are 
so  few  and  unsatisfactory.  We  may  note,  however,  that  there  seems  to 
be  no  enlargement  of  the  liver  downward,  no  bile  staining  of  the  skin 
or  conjunctiva,  none  of  the  ordinary  causes  for  cirrhosis,  hepatic  abscess, 
passive  congestion,  amyloid  or  fatty  metamorphosis,  no  change  in  the 
spleen,  glands,  or  blood  to  suggest  leukemia  or  Hodgkin's  disease. 
This  is  the  best  that  we  can  do  to  exclude  liver  disease.  Had  these  same 
signs  appeared  in  the  back  following  an  appendicitis,  amebic  dysentery, 
or  cholelithiasis,  the  situation  w^ould  suggest  hepatic  abscess. 

I  once  made  a  diagnosis  of  purulent  pleural  effusion  in  a  case  bearing 
a  good  deal  of  resemblance  to  this  one.  I  put  in  a  needle  an  inch  and  a 
half  below  the  angle  of  the  scapula,  drew  pus,  and  promptly  handed  over 
the  case  to  a  surgeon  for  drainage.  He  opened  the  pleura,  found  it 
smooth  and  clean,  and  indulged  in  disparaging  remarks  on  medical  diag- 
nosis. Further  exploration,  however,  showed  that  the  diaphragm  was 
pushed  up  nearly  to  the  angle  of  the  scapula,  and  that  through  its  domed 
surface  fluctuation  could  be  detected.  A  second  ]umcture,  ten  days  later, 
after  the  pleura  had  healed  without  infection,  liberated  a  quart  of  pus 
from  the  region  of  the  kidney.  Since  that  time  I  have  always  remem- 
bered the  possiljility  of  perinephritic  or  subdiaphragmatic  abscess  when 
dealing  with  what  appears  at  first  sight  to  be  an  effusion  (serous  or  puru- 
lent) at  the  right  base.  The  presence  of  leukocytes  in  the  urine  makes 
it  all  the  more  necessary  to  consider  the  kidney  in  this  case,  but  we  must 
first  make  sure  that  those  leukocytes  come  from  the  urinary  tract  by 
obtaining  a  catheter  specimen  of  urine.  When  this  was  done,  the  urinary 
sediment  no  longer  showed  leukocytes,  and  as  there  were  no  other  facts 
pointing  distinctly  to  the  kidney,  I  returned  to  my  original  idea — 
pleurisy  at  the  right  base. 

This  case  is  one  of  many  which  exemplify  the  long  duration  of  pain 
and  of  physical  signs  after  the  healing  of  a  pleural  effusion.  Perhaps 
in  the  majority  of  cases  there  is  more  or  less  suffering  for  a  year. 

Outcome. — The  pain  remained  mostly  in  the  back,  and  not  in  the 
side,  during  the  five  days  of  her  stay  in  the  hospital,  but  soon  disappeared 
with  rest,  full  diet,  and  counterirritation. 

Diagnosis. — Old  pleurisy. 


AXILLARY   PAIN 


Case  160 


319 


A  typewriter  of  twenty-three  lost  her  mother  and  one  brother  of 
phthisis.  Two  and  a  half  years  ago  she  was  in  bed  several  weeks  on 
account  of  pain  in  the  left  axilla.    The  whole  attack  lasted  three  months. 

Lately  she  has  noticed  pain  in  the  left  side  when  she  is  nervous — 
sharp  for  a  few  minutes,  and  leaving  an  ache  for  two  or  three  days  after- 
ward. Sometimes  exertion  relieves  it.  Coughing  or  sneezing  does  not 
increase  it. 

Five  months  ago  the  pain  increased.  For  six  weeks  she  slept  almost 
none  and  walked  the  floor  much.  Her  weight  fell  from  132  to  108. 
The  pain  is  chiefly  in  the  left  side,  but  there  is  also  a  constant  sense 
of  pressure  in  the  right  breast  and  back,  with  occasional  sharp  pains. 
Suffering  is  worse  at  night.  She  has  a  good  deal  of  indigestion  and  con- 
stipation. 

Examination. — Cardiac  apex  in  fifth  space,  nipple-line.  Accom- 
panying the  first  sound  is  a  systolic  murmur,  loudest  at  the  apex,  but 
audible  also  over  the  whole  precordia  and  in  the  left  axilla.  The  pul- 
monic second  sound  is  slightly  louder  than  the  aortic. 

Tender  spots  near  the  left  lower  scapular  edge,  in  post-axillary  line, 
in  the  axillary  line  in  fifth,  sixth,  seventh  spaces,  and  along  sternal  border 
[fourth  to  eighth  ribs]  were  found.     Sensation  normal. 

Discussion. — In  view  of  the  site  of  the  pain  and  the  family  history 
of  tuberculosis,  it  would  be  wrong  not  to  consider  pleurisy  in  this  case; 
but  there  was  no  definite  evidence  of  it  on  physical  examination,  and 
without  such  evidence  the  diagnosis  can  never  be  made. 

Pain  due  to  dyspepsia  and  flatulence  would  hardly  be  so  constant, 
and  this  same  characteristic  excludes  both  types  of  angina  pectoris. 
Muscular  pains  (pleurodynia)  would  show  exacerbation  rather  than 
relief  by  exertion.  Of  local  diseases  of  the  chest-wall  we  haxe  also  no 
evidence. 

Intercostal  neuralgia  is  characterized  by  pain  like  that  here  described, 
and  especially  by  tender  points  corrcsi)onding  approximately  with  those 
which  physical  examination  has  revealed.  I  believe  intercostal  neuralgia 
to  be  a  rare  disease,  although  the  diagnosis  of  it  is  so  common,  by 
intercostal  neuralgia  one  means  ordinarily  the  so-called  ''  ])rimar}-  "  type, 
imrelated  to  any  cause  of  ])ressiire,  such  as  aneurysm  or  spondylitis. 
Pressure  pains  of  this  tvpe  are,  of  course,  by  no  means  uncommon, 
but  ])rimary  intercostal  neuralgia  unaccompanied  by  herpi-s  and  without 
any  known  cause  is,  1  believe,  distinctly  rare.  The  cha^nosis,  like 
all  diagnoses  of  a  "primary  "  or  obscure  lesion,  is  one  with  whicli  we  are 


320  DIFFERENTIAL  DIAGNOSIS 

never  quite  content,  and  which  we  can  tolerate  only  when  we  have  done 
our  best,  by  rigid  scrutiny  and  thorough  sifting  of  all  other  recognized 
possibilities,  to  find  a  cause.  In  the  present  case,  for  example,  I  should 
not  be  satisfied  unless  disease  of  the  spinal  column  had  been,  so  far  as 
possible,  excluded. 

Outcome. — The  pain  gradually  disappeared  in  six  weeks.  Many 
forms  of  treatment  were  tried,  but  none  of  them  had  any  effect  that  I 
could  discover. 

D i agno sis . — Intercostal  neuralgia . 

Case  161 

An  alcoholic  Irish  teamster  of  twenty-eight  has  noticed  for  a  week  a 
pain  in  his  right  lower  axilla.  The  pain  has  several  times  been  associated 
with  vomiting  and  a  slight  cough.     No  injury  is  remembered. 

Family  and  past  history  good. 

Physical  examination  is  negative,  save  for  a  rounded  swelling  about 
15  cm,  in  diameter  near  the  right  costal  margin  in  the  axilla.  The 
swelling  is  brawny,  with  a  slightly  fluctuant  crater  in  the  center. 

Discussion. — There  seems  every  reason  to  believe  that  the  pain  and 
the  tumor  are  connected  in  this  case.  It  remains  to  ask,  WTiat  is  the  nature 
of  the  tumor? 

The  commonest  causes  are:  septic  osteomyelitis  or  tuberculous  osteo- 
myelitis of  a  rib.  The  patient  might  have  broken  one  or  more  ribs  with- 
out knowing  it  during  one  of  his  drinking  bouts,  but  the  resulting  cal- 
luses would  not  produce  a  mass  like  that  here  described, 

A  fatty  tumor  or  an  empyema  necessitatis  would  not  have  a  brawny 
surface.  Either  of  these  lesions,  if  fluctuant,  would  be  fluctuant  through- 
out. Malignant  disease  of  the  chest-wall  does  not  often  show  itself 
at  this  point.  Actinomycosis  cannot  be  excluded;  it  is,  however,  a  rare 
lesion,  and  the  commoner  causes  of  a  swelling  at  this  point  should  be  con- 
sidered first. 

Further  diagnosis  is  impossible  without  incision. 

Outcome. — Two  ounces  of  pus  were  removed  by  incision  and  a  sinus 
found  leading  to  a  rib.  Rough  bare  bone  was  found  at  the  bottom  of 
the  sinus.  There  was  no  evidence  of  actinomyces.  The  patient  seemed 
greatly  debilitated. 

Diagnosis. — Costal  tuberculosis. 

Case  162 

An  unoccupied  girl  of  twent}'-eight  entered  the  hospital  January  15, 
1908,     Nine  months  before  she  caught  cold  at  a  dance,  and  a  week  after 


AXILLARY    PAIN 


321 


began  to  have  pain  in  the  left  chest.  Ever  since  it  has  been  a  constant  . 
ache,  at  times  becoming  severe,  worse  after  eating;  it  is  not  affected 
by  respiration  or  motion.  Her  appetite  is  good,  but  she  has  complained 
of  a  great  deal  of  "  gas  upon  her  stomach,"  and  for  some  months  has  lived 
upon  a  diet  excluding  meat  and  eggs,  sweets,  salt,  and  fried  stuff.  She 
never  vomits.  Her  bowels  are  constipated,  and  she  has  considerable 
dysjmea  on  exertion.  One  year  ago  she  weighed  150  pounds;  she  thinks 
she  has  lost  weight  since. 

Physical  examination  shows  a  rather  obese  girl  weighing  149^  pounds. 
There  is  a  harsh  systolic  murmur  audible  all  o\er  the  precordia,  but 
not  transmitted  elsewhere.  The  apex  is  neither  visible  nor  palpable. 
The  left  border  of  dulness  is  in  the  nipple-line  and  fifth  space.  The 
aortic  second  sound  is  louder  than  the  pulmonic  second  sound.  Physical 
examination,  including  blood  and  urine,  is  otherwise  normal. 

Discussion. — The  only  objective  abnormality  in  the  physical  exam- 
ination is  the  cardiac  murmur  and  the  accentuation  of  the  aortic  second 
sound.  '  These  items  are  not  sufficient,  separately  or  in  combination, 
to  warrant  any  inference  of  disease.  The  histor}'  shows  that  she  has  been 
starving  herself,  yet  on  physical  examination  she  is  obese.  Possiljly 
she  is  trying  to  reduce  her  weight,  which  may  ha^■e  been  greater  six 
months  ago. 

In  the  absence  of  any  local  cause  for  the  pain  one  naturally  thinks 
of  neuralgia,  especially  since  the  diet  is  so  insufficient.  But  there  are  no 
tender  ])oints  corresponding  to  the  nerve  exits,  while  the  fact  that  ])ain 
is  worse  after  eating  is  very  uncharacteristic  of  neuralgia.  While  this 
diagnosis  cannot  1je  positively  excluded,  it  seems  ratlicr  unlikely. 

Muscular  pain  (])leurodynia)  should  be  more  distinctly  related  to  ex- 
ertion and  less  to  food. 

In  vic\^■  of  these  facts  and  of  the  al)sence  of  any  a])parent  connection 
between  the  cardiac  murmur  and  the  j)ain,  it  seems  reasonal)le  tobelie\e 
that  it  is  due  to  a  digestixe  disturbance  favored  by  insulTicient  food 
and  associated  witli  gaseous  distention.  On  p.  28S  I  have  already-  men- 
tioned the  great  frc(|uency  of  axillary  pain  due  to  this  cause.  Such  ]«ain 
is  \ery  common  as  an  element  in  the  clinical  ])icture  (>f  the  gastric  neur()>c>, 
witli  or  without  starxation. 

Xc)  cause  of  stomach  trouble  in  women  is  commoiier  than  starxation. 
Tlie  \icious  circle  is  establislied  in  tlie  following  maiuuT:  Some  teni]io 
rary  fatigue  or  depression  of  \italit\-  results  in  digestixc-  (ii>U;rl)ante. 
The  food  eaten  last  or  most  abundanth'  is  blamed  b\-  the  i>aiieni  and 
excluded  from  the  subsetnient  meals.  l)igesti\e  disturWanee  eoiiiiii;:e>. 
Other  foods  are  exchuk'd.     The  nutrition  of  the  wh.oK'  !)o>h.  iiuludinL' 


322 


DIFFERENTIAL  DIAGNOSIS 


that  of  the  stomach  itself,  begins  to  suffer,  and  digestion  is  still  further 
delayed  by  gastric  stasis  or  insufficient  secretion.  The  suffering  thus 
produced  makes  the  patient  aspirate  air  into  the  stomach  ["cribbing"], 
which  in  time  increases  the  discomfort  and  renders  her  still  more  timid 
about  eating.  The  circle  is  then  complete.  To  break  it  one  must  force 
the  patient  to  eat,  despite  considerable  pain,  until  some  gain  can  be  made 
in  the  general  and  so  in  the  local  nutrition.  A  weakened  stomach,  like 
a  weakened  muscle,  cannot  be  strengthened  without  exercise,  and  this 
entails,  for  a  time,  increase  of  suffering. 

Outcome. — The  patient  was  given  a  full  diet,  a  tight  swathe,  ^ 
dram  bicarbonate  of  soda  after  meals,  and  half  a  dram  of  the  elixir  of  the 
valerianate  of  ammonia  before  meals. 

By  January  21st  she  seemed  perfectly  well  and  able  to  go  home. 

Diagnosis. — Starvation, 


AXILLARY    PAIN 


323 


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CHAPTER  XI 
PAIN  IN  THE  ARMS 

Case  163 

A  THEATRICAL  ad\'ance  agent  of  thirty-ihe  entered  the  hospital  January 
lo,  1907.  Ten  days  ago  he  strained  his  arm  while  swinging  on  a  trapeze. 
A  week  ago  he  was  suddenly  taken  with  aching  and  soreness  in  the 
muscles  of  the  right  arm,  with  a  slighter  amount  of  pain  in  the  other  arm 
and  in  the  legs.  The  joints  were  not  affected,  and  there  was  no  fever  or 
chill,  but  the  right  arm  was  somewhat  swollen  above  the  elbow,  where  it 
was  more  tender  than  in  any  other  part.  He  had  severe,  constant,  frontal 
headache  and  a  harassing,  dry  cough.  He  stayed  in  bed  for  the  first 
day,  but,  feeling  no  better,  got  up  again  and  has  been  up  most  of  the  time 
ever  since.  I'our  days  ago  he  began  to  be  short  of  breath,  especially  on 
exertion,  and  for  three  days  he  has  had  chilly  sensations.  To-day  he 
complains  chiefly  of  dyspnea,  cough,  soreness  all  o\er  his  body,  head- 
ache, weakness,  and  a  sharp  pain  in  his  right  wrist  on  motion.  He 
gets  up  three  or  four  times  at  night  to  pass  his  water. 

On  physical  examination,  temperature,  pulse,  rcs])iration,  blood,  and 
urine  were  found  to  be  normal.  The  patient  looked  sick  and  Ijreathed 
with  some  difficulty.  The  lungs  were  slightly  dull  in  both  backs,  and 
showed  many  fine  and  coarse  rales  with  a  few  squeaks  on  both  sides. 
The  heart  was  negative,  likewise  the  abdomen.  The  rales  in  the  chest 
disappeared  the  next  day.  The  ])rincipal  complaint  thereafter  was  of 
pain  in  the  whole  right  arm,  and  in  it  there  were  slight  general  swelling  and 
a])parcntly  great  tenderness.  The  arm  was  held  rigid  most  of  the  time. 
Dr.  Goldthwait  found  nothing  a1)normal  about  the  bursa>  or  joints. 

The  pain  did  not  pre\ent  sleep  at  all,  and  the  tem])erature  remained 
normal. 

On  the  eighteenth  of  January  the  patient  drop])ed  and  broke  a  cu]). 
Immediately  after  this  he  had  a  con\"ulsion,  in  which  his  body  became 
rigid  and  his  eyes  rolled  up,  while  the  lids,  tlickered. 

Discussion. — All  tliat  ])hysical  examination  re\eals  in  this  case  is  the 
e\'idence  of  a  sliglit  bronchitis  and  a  tender  arm,  very  jjossibly  due  to  a 
strain.  There  is  no  evidence  of  inflammation  or  of  any  lesion  of  ])one  or 
;!24 


Causes  of  Brachial  Pain 


VARIOUS  TYPES  OF  ARTHRITIS  (INFECTIOUS,  ATROPHIC,   HYPERTROPHIC) 


SUBACROMIAL    AND^ 


S  U  B  C  O  R  A  C  O  I  D  !-  ^^■■■■^^^^iHHBHB^^HI^^iHI^H    203 
BURSITIS 


FATIGUE    AND    OC- 
CUPATION       NEU-  h  B^^^^i^^^^HH  91 
ROSIS 


OSTEOMYELITIS 
HUMERI 


20 


ANEURYSM  WM  14 

NEURALGIA  (CAUSE?)    WM  10 

MEDIASTINALTUMOR  ■  7 

NEOPLASM       OF] 
THEARMAND'H  4 

SHOULDER  i 

CERVICAL  RIB  |  3 

ANGINA  PECTORIS         |  1 

Amonc,^  the  other  causes  not  here  represented  are: 

(/i)  Wounds,  with  or  without  l\-nip]ian<4itis  or  thrombosis  : 

(/>)   l^ruises,  fractures,  sprains,  and  strains  ; 

{(■}   l'olioni)-eh'tis  and  cortical  initation  (tumor,  i^umma). 


PAIN   IN   THE   ARMS  327 

joint.  The  pain  does  not  follow  the  course  of  any  nerve,  is  independent 
of  exertion,  and  associated  with  no  evidence  of  cardiac  or  vascular  disease. 
Cervical  rib,  aneurysm,  and  tumor  were  excluded  by  careful  examination. 

In  view  of  all  this  negative  evidence,  and  in  consideration  of  certain 
neurotic  mannerisms  which  were  obvious,  but  not  easily  described,  we 
were  strongly  inclined  from  the  outset  of  the  case  toward  the  diagnosis  of 
traumatic  neurosis.  After  the  fit,  which  was  clearly  hysteric  in  nature, 
we  felt  much  surer  of  our  previous  diagnosis,  and  instituted  treatment 
based  upon  it. 

Outcome. — From  the  fit  above  described  he  could  not  at  once  be 
aroused.  He  was,  therefore,  ignored,  and  after  about  twenty  minutes  he 
sat  up  and  acted  as  if  nothing  had  happened.  Up  to  this  time  the  arm 
had  been  held  rigidly,  and  all  attempts  to  move  it  had  been  resisted — 
as  he  said,  because  of  severe  pain.  After  the  convulsion  he  was  given  a 
severe  scolding,  and  the  arm  was  raised  and  the  fingers  were  bent  and 
straightened  again  by  force  for  about  five  minutes,  in  spite  of  his  shrieks 
and  protestations.  Motions  not  antici])ated  by  the  patient  were  found 
to  ])e  free.  The  next  day  the  patient  was  up  and  about  the  ward,  the 
use  of  his  arm  as  good  as  ever,  and  there  was  no  sign  of  his  previous 
incapacity.  He  is  now  anxious  to  go  out  and  get  to  work.  The  chest  is 
clear,  and  he  was  discharged  well. 

It  is  worth  noting  in  this  case  that  there  was  no  suit  for  damages  in 
contemplation.  Some  writers  on  traumatic  neurosis  and  many  lawyers 
engaged  in  defending  suits  for  damages  try  to  })ersuade  us  that  the  ex- 
])ectation  of  a  money  payment  as  the  result  of  litigation  })roduces  most 
of  the  symptoms  of  the  traumatic  neuroses.  Cases  like  that  here  de- 
scribed upset  such  assertions. 

Diagnosis. — Traumatic  neurosis. 

Case  164 

A  Turkish  jeweler  forty-five  years  old  entered  the  hospital  December 
26,  1907.  His  family  history  and  ]xist  history  were  not  remarkal)lc. 
He  denied  venereal  disease.  Three  years  ago  he  had  his  first  attack  of 
"rheumatism  "  in  the  right  hand  and  forearm,  later  in  tlie  otlier  hand  and 
other  arm.  There  was  no  in\'()h"cnient  of  the  joints  and  no  increase  of 
pain  l)y  motion.  Six  months  later  the  pain  cxlendcd  U])  to  the  shoulders 
and  to  tlie  neck.  For  this  rheumatism  he  has  been  treated  by  man;-  doc 
tors,  but  without  relief.  Three  vears  ago  he  gave  u]^  work  and  has  ne\er 
resumed  it.  Fifteen  months  ago  lu-lx'gan  to  liaxc  a  dist'-es>inu  cough 
with  foamy  sputum  and  this  has  continued  e\-er  since.  Vov  about  the 
same  ])eriod  lie  has  noticed  hoarseness  and  dyspnea  on  exertion.     For 


328  DIFFERENTIAL   DIAGNOSIS 

the  ])ast  live  months  he  has  been  unable  to  lie  down  at  night.  His  appe- 
tite remains  excellent,  but  he  sleej^s  ])oorly. 

A  loud  ringing  cough  is  the  patient's  most  striking  symptom,  and  no 
cause  for  this  could  be  found  on  examination  of  the  lungs.  Over  the 
base  of  the  heart  a  loud,  harsh  systolic  murmur  is  heard.  There  is  an 
area  of  percussion  dulness  as  shown  in  the  diagram  (Fig.  56).  Physical 
examination  is  otherwise  negative. 

Discussion. — In  view  of  the  symptoms  Avhich  have  recently  developed 
in  this  case  it  no  longer  presents  any  diagnostic  problems  of  special 
difficulty.  Any  patient  who  has  a  long-standing  violent  cough,  with 
dyspnea,  hoarseness,  pain  in  the  arm,  and  a  dull  area  over  the  manu- 
brium, with  negative  heart  and  lungs,  has  either  aortic  aneurysm  or  medi- 
astinal tumor  in  all  human  probability.  To  this  residual  problem  I  will 
return  later. 

The  great  interest  of  the  case  centers  in  the  three  years  which  ha\e 
led  up  to  the  appearance  of  the  present  distinctive  symptoms  of  medi- 
astinal pressure.  Until  very  recently  this  case  was  regarded,  as  most 
such  cases  are,  as  one  of  "rheumatism."  I  have  taken  occasion  in  A'ari- 
ous  parts  of  this  book  to  illustrate  the  dangers  and  fallacies  inherent  in 
most  diagnoses  of  rheumatism.  Xo  other  word  in  the  doctor's  vocabu- 
lary stands  so  frequently  for  a  dangerous  mistake,  one  for  which  the 
physician  bitterly  reproaches  himself  when  he  discovers  it.  How  are 
these  dangers  to  be  avoided? 

1.  Let  us  never  use  the  word  rheumatism  unless  there  is  evidence  of 
acute  infection,  with  distinct  and  predominant  in^■olvement  of  joints. 
Muscular  pains  will  then  be  ruled  out,  their  distinguishing  characteristic 
being  an  increase  of  pain,  especially  when  the  muscle  is  used.  The 
recognition  of  nerve  pains,  distinguished  by  the  close  relation  of  the 
suffering  to  the  anatomic  distribution  of  one  or  more  nerves,  will  still 
further  to  restrict  the  unchartered  freedom  with  which  we  pronounce  the 
word  "rheumatism."  Pain  due  to  inflammation  involving  the  subcu- 
taneous tissues  or  deeper  ])arts  may  ordinarily  be  recognized  ])y  the  other 
familiar  e\idences  of  exudation  ^tenderness,  redness,  swelling,  heat). 

2.  When  muscular  pains,  neuralgias,  and  subcutaneous  exudations 
are  excluded,  we  have  left  a  very  large  grouy)  of  lesions  in  or  near  the 
joints — bony  outgrowtlis,  periosteal  inflammations,  se})tic  and  tulxTcu- 
lous  osteomyelitis,  malignant  disease  of  the  Ijone,  cartilage.,  or  ])erios- 
teum,  joint  fringes  and  foreign  bodies,  joint  atro])liies.  traumatic  syno- 
^'itis,  gout,  hemophilic  arthritis,  joint  suppurations,  and  other  less  com- 
mon affections.  From  all  these  true  rheumatism  (i.  f.,  acute  injections 
polyartJiritis  of  unknoivn  origin)  may  be  distinguished,  in  tlie  \ast  major- 


rig.  56. — rii\.--i(al  signs  in  a  cast-  diarac  trrizcd  for  nearh  tlirue  \ears  ]<y  pain  ii;  tl;c  arii;s. 


PAIN   IX    THE    ARMS  329 

ity  of  cases,  by  the  fact  that  it  produces  no  permanent  changes  in  anv  of 
the  joint  structures  and  gives  a  negative  :v-ray  picture.  Joint  fringes, 
traumatic  synovitis,  and  suppurative  arthritis  may  show  nothing  charac- 
teristic in  the  ^"-ray  picture,  but  the  history  and  the  accompanying  svmp- 
toms  usually  make  the  diagnosis  clear.  The  point  which  must  be  in- 
sisted ui)on,  however,  is  that  if  we  are  to  be  even  approximatel}-  secure  in 
a  diagnosis  of  rheumatism  we  must  have  a  satisfactory  rc-ra}'  picture  of 
the  joint  in  any  case  persisting  over  two  weeks. 

3.  It  is,  I  trust,  worth  while  to  mention  here  some  of  the  diseases 
which  I  have  known  frequently  diagnosed  as  rheumatism.  The  list 
includes  many  cases  of  tabes  dorsalis,  aortic  aneurysm,  and  osteomyelitis 
(septic  or  tuberculous),  a  smaller  num}:)er  of  cases  of  malignant  disease 
involving  the  mediastinal,  prevertebral,  or  abdominal  glands  and  the  long 
bones;  also  a  good  many  cases  of  pressure  neuritis  (due  to  spondylitis, 
subacromial  bursitis,  or  cer\ical  rib). 

Returning  now  to  the  case  under  discussion,  we  must  attempt  a 
diagnosis  between  aneurysm  and  mediastinal  tumor.  The  strongest 
evidence  against  tumor  is  the  long  duration  of  the  symptoms  witliout 
any  involvement  of  the  external  l}m])hatic  glands  and  without  more  ob- 
vious de])ression  and  exhaustion  of  the  })atient's  ])hysical  condition. 
As  has  been  already  said,  diagnostic  problems  in^■olving  the  differentia- 
tion between  aneurysm  and  mediastinal  tumor  are  usually  settled  sooner 
or  later  ])y  the  disco\ery  of  aneurysm. 

Outcome. — The  .r-ray  confirmed  the  diagnosis  of  aneurysm.  On 
the  eighth  of  January  a  diastolic  murmur  was  noted,  l^est  heard  at  the 
a])ex.  The  pulse  showed  no  change.  At  times  the  murmur  was  loudest 
in  the  anterior  axillary  line  in  the  fifth  s])acc,  and  could  be  heard  indis- 
tinctly as  far  l)ack  as  the  ])oslerior  axillary  line.  The  murmur  was  long 
and  wholly  re])laced  the  second  sound  at  the  a])ex.  Gelatin  injections 
produced  great  ])ain,  l)ut  no  relief. 

The  patient  left  the  hos])ital  on  February  24th. 

Diagnosis. — Aneurysm  (called  rheumatism). 

Case  165 

A  washwoman  of  fiftv-nine  entered  tlic  hos])ital  ]'\'bruary  10.  locS. 
Three  \'ears  ago  slie  liad  what  she  \vas  told  was  a  Iifuigu  tumor  in  if.r 
left  breast,  which  was  remowd  in  ScptemljiT.  1005.  <  )thiT\\  isc  slu-  iia- 
I)ci'n  well  until  three  months  ago,  wlicn  she  began  to  notice  ])ain  on  UK'tion 
of  the  right  u])per  arm  and  shoulder.  Since  Christmas,  TO07,  slu'  !ia> 
i)een  able,  to  do  little  or  no  \\"ork.  Tntil  \"er\'  recenth'  there  lia^  Ihtp  no 
])ain  when   the  arm  is   kepi  still.     Coughing  ])roduces  jiain;    lire;!tr.ini: 


330 


DIFFERENTIAL  DIAGNOSIS 


does  not.     For  two  weeks  she  has  had  a  somewhat  similar  soreness  in 
the  right  groin  and  hip. 

Physical  examination  showed  no  emaciation,  normal  temperature, 
pulse,  respiration,  blood,  and  urine.  The  chest  and  abdomen  were 
also  normal,  but  it  was  found  that  the  patient  could  not  raise  the  right 
arm  without  marked  pain.  The  greatest  tenderness  was  in  the  front  of 
the  upper  arm.     There  was  no  atrophy. 

Counterirritation  and  small  doses  of  morphin  did  not  relieve  the  pain 
at  all.  On  the  nineteenth  it  was  found  that  the  right  arm  and  the  right 
side  of  the  chest  were  almost  completely  anesthetic.  An  orthopedic 
consultant  considered  the  case  one  of  subacromial  or  subcoracoid  bursitis. 
A  neurologic  consultant  agreed.  The  pain  in  the  right  groin  disappeared 
after  a  short  stay  in  the  hospital. 

Discussion. — Against  the  diagnosis  of  subacromial  bursitis  the  most 
important  datum  is  the  area  of  anesthesia,  which  involves  not  only  the 
right  arm,  but  the  right  side  of  the  chest,  and  was  apparently  overlooked 
by  the  other  consultants.     I  have  never  heard  of  a  bursitis  producin^^ 
wide-spread  an  anesthesia.     Less  important  considerations  antagonistic  \ 
I  to  the  diagnosis  of  bursitis  are  the  absence  of  any  trauma  or  of  any  e^•i-  j 
■  dence  that  abduction  or  rotation  is  especially  painful,  and  the  fact  that  \ 
the  pain  is  not  especially  worse  at  night.     In  the  gi^eat  majority  of  cases  -^^ 
of  bursitis  the  opposite  is  true. 

Three  months'  suffering  with  shoulder  pain  and  disability,  associated 
with  so  wide-spread  an  anesthesia,  should  always  lead  at  once  to  the  in- 
vestigation of  the  mediastinum  by  radioscopy,  especially  since  we  have 
no  positive  evidence  that  the  mammary  tumor  removed  in  1905  was  as 
benign  as  the  patient  had  been  led  to  suppose. 

Outcome. — X-ray  taken  on  the  twenty-sixth  showed  a  wide  shadow 
in  the  mediastinum.  On  March  4th  the  patient  began  to  complain  of 
a  smothering  sensation  in  the  chest,  and  some  edema  appeared  in  the 
right  hand.  The  veins  in  the  neck,  especially  on  the  right,  now  began 
to  be  engorged,  though  the  pain  was  diminished.  The  patient  left  the 
hospital  March  21st,  not  relieved. 

Diagnosis. — -Mediastinal  neoplasm  (metastatic). 

Case  166 

A  clerk  of  forty-nine  entered  the  hospital  June  25,  1908.  He  had 
previously  been  in  the  hospital  twenty-two  years  before,  suffering  from 
what  was  considered  facial  neuralgia,  but  since  that  time  he  had  been 
perfectly  well  until  five  months  ago,  when  he  began  to  have  sharp  pain 
under  the  rifdit  shoulder  and  fmallv  down  the  whole  of  the  riszht  arm. 


PAIN   IN   THE   ARMS 


33^ 


After  the  first  two  or  three  days  the  pain  never  bothered  him  at  night,  but 
seven  weeks  ago  it  compelled  him  to  give  up  work.  He  has  had  to  have 
morphin  for  it  once.  The  pain  is  most  severe  near  the  elbow.  The  joints 
do  not  seem  to  be  involved.  There  is  no  limitation  of  motion.  His 
appetite  and  sleep  are  poor.  For  a  month  he  has  had  fi\'e  or  six  loose 
movements  of  the  bowels  a  da}-. 

Physical  examination  was  entirely  negative.  There  was  no  tender- 
ness along  the  course  of  the  nerve -trunks.  A'-ray  showed  nothing  ab- 
normal in  the  chest,  the  neck,  or  in  the  joints.  On  the  second  day  of 
his  stay  in  the  hospital  he  had  a  return  of  the  facial  neuralgia,  which  he 
had  not  j)reviously  had  for  twenty-two  years. 

Discussion. — Neuralgia,  /'.  e.,  nerve  pain  of  unknown  origin,  is 
always  an  unsatisfactory  diagnosis,  and  one  that  we  should  make  with 
the  greatest  hesitation  and  as  a  consequence  of  a  long  process  of  exclusion, 
whereby  all  known  causes  for  such  a  pain  are  sought  for  without  result. 
In  the  present  case  we  can  make  a  diagnosis  of  neuralgia  only  by  satis- 
fying ourselves  that  there  is: 

(a)  No  relation  to  exertion  (angina  pectoris). 

(b)  No  injury  of  the  part  (unrecognized  fracture,  traumatic  neuritis, 
contusion  or  traumatic  traction  of  nerve-trunks,  tearing  of  muscular, 
capsular,  or  ligamentous  fibers). 

ic)_  No  evidence  of  bursitis  (limitation  of  motion,  tenderness  at  the 
])oint  of  the  shoulder  or  in  the  region  of  the  bicipital  groove). 

id)  No  signs  of  inflammation  involving  the  veins,  lym])hatics,  or  sub- 
cutaneous tissues. 

(c)  No  local  lesion  of  the  bone  or  periosteum  (sej)tic  or  tuberculous 
ostcomvelitis,  periostitis,  benign  or  malignant  neoplasm). 

(/)  No  e\idences  of  pressure,  such  as  cervical  rib,  aneurysm,  mediasti- 
nal, suT:»racla^•icuIar,  or  axillary  glands,  or  j)\ilmonary  tumor. 

(^')  No  atrophic  or  hypertrophic  arthritis  (.v-ray  e\idence). 

(h)  No  occupation  neurosis. 

(/)  No  systemic,  infectious,  or  Ncrtebral  disease. 

In  the  present  case  it  seems  possible,  by  rigid  cross-questioning  and 
examination,  to  exclude  all  these  possibilities.  We  had  reason  to  believe 
that  the  ])atient  was  already  subject  to  ner\e  ])ain  of  unknown  source. 
The  diagnosis  of  brachial  neuralgia  was,  therefore,  linally  made. 

Outcome. —  Under  aspirin,  to  grains  e\ery  liour  for  eightrcn  hor.rs, 
hot  and  cold  douching,  rest,  and  generous  diet,  the  pain  was  \it\'  nv.'Ah 
relieved  by  the  second  of  July.  On  tlie  seventh  he  left  the  hosi'ital  prac- 
tically wfU. 

Diagnosis. — Neuralgia. 


^^2  DIFFERENTIAL    DIAGNOSIS 

Case  167 

A  colored  housewife  of  twenty-eight  entered  the  hospital  July  23, 
1907.  She  has  ncN'er  menstruated,  but  has  otherwise  been  well  until 
seven  days  ago,  when  she  woke  up  with  a  sore  throat  and  stiffness  through- 
out the  whole  left  side,  such  that  she  could  not  raise  her  arm  or  leg. 
Since  then  she  has  had  much  pain  in  both  arms  and  has  taken  a  great 
deal  of  morphin.  At  entrance  the  arms,  knees,  and  lower  legs  were 
tender  and  swollen,  the  tenderness  being  as  great  in  the  muscles  as  at  the 
joints.  Physical  examination  was  otherwise  negative,  though  the  tem- 
perature ranged  between  ico°  and  101°  F.  for  a  week,  gradually  falling 
to  normal  in  the  course  of  another  week.  The  blood  sho\\ed  a  moderate 
polynuclear  leukocytosis.  The  urine  contained  bile  for  the  first  five  days, 
and  she  had  severe  nose-bleed  several  times  in  the  first  four  days  of  her 
stay.     The  conjunctivae  were  distinctly  bile-stained. 

Discussion. — It  seems  obvious  that  we  are  dealing  with  an  infection 
of  some  kind.  The  well-marked  pyrexia,  the  jaundice  (hemolytic  pre- 
sumably), the  polynuclear  leukocytosis,  and  the  evidences  of  local  in- 
flammation all  point  to  a  bacterial  origin. 

Swelling  of  the  extremities  is  not  a  common  symptom  when  the  heart 
and  kidneys  are  sound,  as  they  appear  to  be  in  this  case.  This  is  especi- 
ally true  of  the  arm.  Occlusion  of  the  vein  by  infectious  thrombosis 
should  produce  a  well-locaHzed  cord-like  induration  along  the  course 
of  one  or  more  veins.     We  ha\'e  nothing  of  the  kind  here. 

Lymphangitis  is  usually  the  result  of  some  infection  involving  a  break 
in  the  skin.  It  generally  produces  a  red  blush,  extending  from  the  point 
of  injury  or  its  neighborhood  up  the  extremity  toward  the  nearest  lymph- 
glands.     But  of  such  an  inflammation  there  is  no  evidence. 

Of  sei^tic  myositis  we  know  so  little  that  it  is  hard  to  make  any  definite 
statements  aljout  it  in  a  diagnostic  discussion.  I  have  never  heard  of  so 
diffuse  a  myositis  except  that  resulting  from  the  disease  next  to  be  men- 
tioned. 

Trichiniasis  might  produce  almost  all  the  svmptoms  in  this  case, 
though  it  is  not  often  limited  to  the  extremities  and  rarelv  associated  with 
so  much  edema. ^  The  jjatient's  color,  the  polynuclear  leukocytosis,  and 
the  absence  of  the  eosinophilia  strengthens  the  case  against  trichiniasis. 

A\'ith  the  exclusion  of  all  these  possibilities,  there  is  nothing  left  but 
an  inflammation  of  the  su])cutaneous  tissue  and  joint  structure,  not  in- 
\"olving  the  ^"eins  or  h'mphatics.  not  due  to  an  infected  wound  or  to  any 

'A  cast  of  trichiniasis  in\'o]\inii  still  mnrf  wide-sprt-ad  t-deina  \vas  r^-f«'ried  Ij}'  Dr. 
Donald  (Irei^jz  in  the  lioston  .M(rd.  and  Surg.  Ji>ur.,  December  t,,  igoy. 


PAIN    IN    THE    ARMS 


333 


known  parasite.  In  the  great  majority  of  such  cases  the  tenderness  and 
swelling  soon  "settle"  in  the  joints,  leaving  the  other  tissues  free.  Be- 
cause of  this  fact  and  because  the  joints  ultimately  recover  entirelv,  such 
cases  are  usually  labeled  "rheumatism."  For  the  reasons  previously 
discussed  on  p.  328,  I  believe  this  term  should  be  restricted  to  articular 
disease  involving  no  permanent  joint  changes  nor  lesions  of  the  subcu- 
taneous tissues  around  the  joints.  The  present  case,  therefore,  should 
be  labeled  ])rovisionally  as  a  cellulitis  and  arthritis  of  unknown  origin. 

Outcome.— The  patient  was  given  hot  fomentations  surrounding  the 
extremities,  and  10  grains  of  sodium  salicylate  every  hour.  Bv  the 
third  of  August  she  was  greatly  improved.  By  the  thirteenth  she  was  up 
and  walking  about,  all  pain  and  swelling  having  gone  excejjt  from  the 
left  hand.     This  also  gradually  got  well  in  the  course  of  six  weeks. 

Diagnosis. — Infectious  cellulitis  with  arthritis. 

Case  168 

An  unmarried  girl  of  eighteen  has  always  been  well  save  for  a  bunch 
over  the  left  collar-bone  which  formed  h\e  years  ago,  broke  and  dis- 
charged for  several  months. 

For  six  months  she  has  had  slight  pain  and  considerable  disal)ility 
in  right  shoulder.  Rotation  is  ])ainful  and  creaky.  l)ut  abduction  is 
not  especially  limited.  The  deltoid  is  very  weak  and  markedly  atro- 
phied. 

Physical  examination,  including  temperature,  })ulse,  respiration, 
blood,  and  urine,  is  otherwise  negati\e. 

Discussion. — Weakness,  soreness,  and  stiffness  of  the  shoulder 
lasting  six  months  make  a  clinical  ])icture  raising  many  diagnostic 
])ossil)ilities  before  our  minds.  Since  the  general  physical  examination 
reveals  notb.ing  abnormal  in  the  internal  \iscera  or  in  an}"  other  i)art  of 
the  body,  we  are  justified  in  fixing  our  attention  u])on  tlie  local  lesion. 

Subacromial  bursitis  might  |)roduce  all  the  symptoms  here  described, 
but  the  history  does  not  suggest  an}'  of  the  ordinar}-  causes  ot  this  disease, 
sucli  as  trauma,  ])rolonged  ll.xation,  or  sej'sis.  If  subse(|uent  examination 
(.v-ray)  re\eals  no  other  disease  of  tlie  bone  or  joint,  bursitis  will  present 
strong  claims  u])on  our  notice. 

Tuberculous  oslcoiuvrlilis  in\()l\ing  the  head  of  the  humerus  nuLiht 
also  account  for  all  tlie  s\-m])toms  of  \\hich  this  ])atit'nt  complains.  'I  lie 
fact  that  she  has  ])re\-iousI\'  had  a  chronic  suppuration  originaliui:  in 
a  bunch  on  the  left  side  of  tlie  neck  1  presiimabl\-  a  tuberciiloii.-  L^laiidi 
inclines  us  toward  tlie  belief  that  the  bone  also  is  tul)er(",ilo;i>.  .\liiioi;L;li 
there  is  no  apparent  iiu'ohenient  of  the  soft  parts  o\erlvitv.:  ihe  joint. 


334  DIFFERENTIAL  DIAGNOSIS 

the  tuberculous  process  may  be  confined  to  the  destruction  of  bone 
{caries  sicca).     Further  evidence  must  be  sought  by  sc-ray  examination. 

Only  by  this  means  can  we  exclude  an  unrecognized  fracture  oj  the 
upper  end  oj  the  humerus.  It  would  be  strange,  however,  if,  in  a 
young  girl  apparently  free  from  disease  of  any  other  part  of  the  body, 
we  should  find  a  fracture  of  the  humerus  without  any  known  trauma. 
In  the  early  stages  of  such  a  lesion  the  history  should  have  mentioned 
the  presence  of  ecchymosis  and  swelling,  especially  on  the  inner  side 
of  the  arm.  Six  months  after  the  time  of  fracture  we  should  expect 
the  symptoms  either  to  be  gone  altogether  or  to  be  associated  with  some 
bony  deformity. 

Circumflex  paralysis  rarely  occurs  without  some  much  more  obvious 
cause  than  is  stated  here.  In  case  of  such  a  paralysis  there  would  be 
no  visible  or  palpable  contraction  of  the  deltoid  fibers  if  the  patient 
were  to  make  an  effort  to  raise  the  arm  (abduction).  In  the  present 
case  there  were  distinct  wrinkling  and  hardening  of  the  deltoid  under 
the  palpating  hand  during  the  patient's  effort,  although  no  considerable 
motion  resulted. 

Atrophic  or  hypertrophic  arthritis  would  be  almost  certain  to  involve 
some  other  joint  to  a  greater  or  lesser  extent.  The  age  and  sex  are 
typical  for  atrophic  arthritis,  not  at  all  so  for  hypertrophic  lesions. 
Further  evidence  regarding  such  disease  could  only  be  obtained  by  .r-ray 
examination. 

A  deep  axillary  abscess,  small  and  high  up  under  the  pectoral, 
sometimes  produces  a  fixation  of  the  shoulder-joint  and  pain  on  any 
motion  involving  it;  but  careful  examination  of  the  upper  axilla  behind 
the  pectoral  should  disclose  a  deep  tenderness  and  induration,  and  there 
should  be  some  fever.  In  the  present  case  such  an  abscess  is  unlikely 
on  account  of  the  long  duration  of  the  symptoms. 

Outcome. — X-ray  showed  considerable  necrosis  of  the  head  of  the 
humerus,  which  was  therefore  excised.  Examination  of  the  portion 
resected  showed  tuberculosis.  The  girl  ultimately  made  a  good  re- 
covery, with  very  fair  use  of  the  arm. 

Diagnosis. — Tuberculosis  of  the  humerus. 

Case  169 

An  Armenian  factory  hand  of  thirty-one  received  a  blow  on  the 
right  shoulder  six  weeks  ago.  Afterward  the  shoulder  swelled  and 
stiffened.  The  patient  is  not  able  to  give  any  more  detailed  history 
of  his  illness. 

Examinatio7i. — There  is  almost  complete  loss  of  active  motion  in 


PAIN    IN    THE    ARMS 


335 


the  right  shoulder.  Passive  motions  are  also  somewhat  restricted  in  all 
directions;  there  is  marked  tenderness  over  the  upper  third  of  the 
humerus.  No  swelling,  no  hollowing  of  the  deltoid,  but  marked  atroj)hy 
of  the  whole  upper  arm.     The  axilla  is  full  of  tender  glands. 

Temperature,  ioo°  to  103°  F.;   leukocytes,  8000. 

Discussion. — The  signs  seem  to  point  toward  some  type  of  osteo- 
myelitis, but  why  does  not  the  man  get  well?  Why  are  there  atrophy 
of  the  whole  arm  and  such  marked  loss  of  power  in  the  shoulder?  Six 
weeks  of  disuse  might  alone  cause  atrophy  and  limitation  of  motion. 
Is  there  some  malignant  disease  behind  it  all,  some  lesion  of  the  central 
nervous  system,  or  tuberculosis?  The  presence  of  temperature  and 
tender  axillary  glands  tends  to  show  that  there  is  still  infection  going 
on,  although  the  leukocyte  count  is  so  low.  The  fact  last  mentioned 
inclines  us  slighdy  toward  tuberculosis  as  the  cause  of  the  osteomyelitis. 

Obviously,  however,  the  chief  need  of  the  case  is  for  an  .Y-ray  examina- 
tion, to  be  followed  in  all  probability  by  a  more  thorough  in\"estigation 
of  the  conditions  below  the  deltoid. 

Cases  of  this  type  ofTer  an  extensive  field  of  possible  alternatives  for 
differential  diagnosis.  Thc_history  of  trauma  makes  it  necessary  to 
consider  fracture  or  dislocation  of  the  humerus  and  subacromial  bursitis. 
Contusion  or  hematoma  would  presumably  have  been  well  before  the 
end  of  six  weeks,  but  there  may  always  be  an  element  of  traumatic 
neurosis  in  the  case. 

On  the  other  hand,  it  is  essential  to  remember  that  the  history  of 
trauma  is  often  evolved  quite  out  of  whole  cloth  by  the  patient,  whose 
mind  imperatively  demands  some  such  explanation  for  a  painful  and 
tender  swelling,  due,  in  fact,  to  neoplasm,  to  tuberculosis,  to  scy)tic 
osteomyelitis,  or  other  disease  in  which  trauma  plays  a  very  subordinate 
r61e. 

Further,  we  must  realize  that  a  subacromial  bursitis  is  sometimes 
brought  about  In'  the  prolonged  immobilization  of  the  shoulder  resulting 
from  a  shoulder  contusion  which  is  coddled  by  a  neurotic  patient  or  an 
overanxious  mother. 

Taking  up  now  these  alternatives,  we  may  eliminate  fracture  and 
dislocation  by  the  negative  results  of  .v-ray  examination;  _liiu:?^itis,  by 
the  absence  of  characteristic  limitations  of  moI)ility;  ne()])lasms,  by  the 
results  of  .v  ray.  Tlie  tenderness  is  distinctly  suggestive  of  osteonncliiis, 
especially  if  neoplasm  can  \)ii  ruled  out.  The  results  of  exploratory- 
incision  will  be  important  here.  Tuberculosis,  whrtlu'r  in  tlu'  !onn 
of  caries  sicca  or  whether  including  subcutaneous  tissurs,  should  be 
shown  up  by  the  results  of  .v-ray  examination. 


33^ 


DIFFERENTIAL   DIAGNOSIS 


Outcome. — A'-ray  showed  a  large  ca\ity  in  the  head  of  the  humerus 
and  a  smaller  one  in  the  shaft;  shoulder-joint  obliterated.  After  ojjera- 
tion,  the  patient  recovered.    The  excised  bone  showed  no  tuberculosis. 

Diagnosis. — Septic  osteomyelitis. 

Case  170 

Two  months  ago  a  teamster's  left  arm  suddenly  became  stiff  and 

pained  at  night  near  the  neck  of  the  humerus.     Two  days  later  the 

fingers  and  palm  began  to  swell  and  to  get  shiny.     Three  days  after  this 

the  whole  arm  swelled.     The  pain  then  extended  into  the  upper  back. 

He  was  then  treated  in  the  South  Framingham 

hospital  for  neuritis,  and  was  two  weeks  in  bed, 

but   without    fever.     Now    he    is    much    better. 

Edema  gone. 

Examination. — All  motions  of  the  left  shoulder 
were  made  voluntarily.  The  muscles  were  still 
very  weak,  and  there  was  tenderness  over  the 
scapula,  which  later  improved  with  counterirrita- 
tion  and  sodium  salic}'late.     A'-ray  negative. 

Discussion. — The  earlier  symptoms  remind 
us  of  tuberculosis  of  the  humerus  or  of  sub- 
acromial bursitis.  But  neither  of  these  diseases 
produces  so  much  s\velling  of  the  lower  arm. 
Tuberculosis  may  be,  with  reasonable  probability, 
excluded  by  the  negative  results  of  .v-rav  ex- 
amination, bursitis  by  the  absence  of  spasm  or 
characteristic  limitation  of  motion  and  tli*-  '^'cs- 
ence  of  diffuse  extensiw  ','fle'";T.i. 

Ihis  edema  might  be  explained  by  the  ])res- 

sure  of  an  intrathoracic  tumor  or  a  cervical   rib 

upon  the  \'eins  of  the  arm,  but  the  fact  that  the    edema   so  prom])tly 

disapjjeared  and  that  physical  examination  shows  no  evidence  of  these 

causes  of  pressure,  suffices  to  exclude  them. 

Swelling  of  the  arm  without  ol)\-ious  cause  is  occasionally  due  to  a 
thrombophlebitis,  but  such  a  diagnosis  cannot  be  made  unless  we  find 
induration  and  tenderness  along  the  course  of  some  vein  or  veins. 

Brachial  neuralgia  is  a  ])Ossible  diagnosis,  although  the  [)resence  of 
edema  and  the  absence  of  tenderness  following  sharply  the  course  of  any 
known  ner\e  make  it  rather  unlikel}'. 

Diffuse  inflammation  of  the  suljcutaneous  tissues  (so-called  cellulitis) 
is  not.  in  my  opinion,  a  \'ery  rare  condition,  c\en  in  the  absence  of  any 


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Fig.    57. — Chart    of 
case    1 70. 


PAIN    IX    THE   ARMS 


337 


known  cause.  We  hear  but  little  of  such  affections,  because  they  are 
apt  to  be  called  muscular  rheumatism,  as  the  present  case  was.  In  view 
of  the  outcome  of  the  case  cellulitis  seems  to  me  to  be  the  best  diagnosis. 

Outcome. — The  patient  made  an  uneventful  recovery  in  the  course 
of  three  weeks. 

Diagnosis. — Cellulitis. 

Case  171 

A  housewife  of  thirty-five  has  suffered  for  many  years  from  "  rheuma- 
tism "  in  her  right  shoulder. 

For  three  years  the  pain  has  been  worse  and  has  been  referred  especi- 
ally to  the  region  of  the  right  clavicle  and  to  the  whole  right  arm.  Some- 
times it  is  localized  at  the  lower  end  of  the  ulna. 

Within  a  month  she  seems  to  be  losing  strength  in  the  arm,  and  the 
pain  often  keeps  her  awake  at  night. 

Examination  shows  a  pulsating  mass  above  the  left  cla\'icle,  ^^•ith  a 
sense  of  firm  resistance  below  and  around  it.  Backward  motions  of  the 
arm  cause  sharp  j)ain.  The  outer  side  of  the  pulsating  mass  is  very 
tender.  There  is  no  considerable  atrophy  or  limitation  of  abduction. 
Temperature  range,  98°  to  99.5°  F.  Pulse,  90  to  120.  Urine  ])ale, 
acid,  1016;  albumin,  slightest  possible  trace.  Sediment.  Numerous 
blood-globules;  small  round  mononuclear  cells,  some  of  which  are  fatty. 
Manv  calcium  oxalate  crystals.     Internal  viscera  negati\e. 

Discussion. — The  diagnosis  was  not  suspected  in  this  case  until  the 
conditions  were  actually  seen  at  operation.  This  seems  to  me  wrong, 
for  there  are  very  few  causes  which  j^roduce  a  pulsating  mass  above  the 
clavicle.  Aneurysm  is  naturally  our  lirst  thought,  but  this  is  a  \er\-  un- 
usual ])lace  for  an  aneurysm,  although  diffuse  dilatations  of  th.e  sub- 
clavian or  carotid  arteries  often  occur  as  a  result  of  aortic  regurgitation 
and  in  connection  with  a  diffuse  dilatation  of  the  arch.  This  condition 
is  not  aneurysm,  and  should  not  be  confounded  with  it.  since  there  is  no 
breaking  of  the  arterial  coats  and  no  tendency  to  end  in  rupture  of  the 
arterv.  Further,  an  aneurysm  of  two  years"  standing  is  \ery  rare  in  this 
situation,  and  the  source  of  the  marked  resistance  around  the  j)ulsating 
mass  would  not  be  explained  by  the  diagnosis  of  aneurysm. 

Can  the  pulsation  be  transmitted  through  some  tumor  or  inland uLir 
VKiss  l)y  a  normal  arterv  beneath?  it  would  seem  \"er\"  unHkely  tiiat  a 
tvunor  wliich  would  ])r()duce  pressure  j)ains  in  tlie'arni  for  three  _\'ears 
should  not  ha\"e  attained  greater  size  and  pulled  the  patient  down  more. 
and  metastasis  woukl  probablv  h,a\e  occurred. 

The  presence  of  a  slight  fe\'er  (U'/es  some  i-olor  to  the  idea  ot  gland- 


338  DIFFERENTIAL   DIAGNOSIS 

ular  luberculosis,  but  such  a  process  rarely  if  ever  causes  much  ])ain,  and 
would  scarcely  ha^•e  existed  so  long  without  abscess  formation. 

Brachial  neuralgia  is  a  diagnosis  which  one  never  has  a  right  to  make 
in  the  presence  of  anything  which  can  possibly  be  interpreted  as  a 
mechanical  cause  of  the  pain  under  investigation.  With  a  mass  like 
that  here  described  the  diagnosis  of  neuralgia  has  no  justification. 

A  pulsating  mass  abo^'e  the  clavicle  means  cen'ical  rib  in  nine  cases 
out  of  ten,  the  pulsation  being  due  to  the  subclavian  artery  which  over- 
lies the  rib,  while  brachial  pain  results  from  pressure  on  the  brachial 
plexus. 

Tlie  firm  resistance  below  and  around  the  pulsating  mass  was  the 
rib  underlying  the  artery.  Had  an  x-ray  been  taken,  the  diagnosis  should 
easily  have  been  clinched  before  operation,  but  even  without  an  rv-ray 
one  might  make  a  reasonably  certain  diagnosis  on  the  history  and  physical 
signs,  provided  one  had  ever  seen  a  similar  case. 

Outcome. — The  brachial  plexus  and  subclavian  artery  were  found  at 
operation  to  be  ele^■ated  on  the  blunt  head  of  a  cervical  rib  which  joined 
the  first  dorsal  rib  about  two  inches  from  the  sternum. 

After  excision  of  the  cervical  rib  the  pain  disappeared  within  ten 
days  and  did  not  return. 

Diagnosis. — Cervical  rib. 

Case  172 

A  very  alcoholic  clerk  of  thirty-three  was  sent  into  the  liospital  for 
"osteomyelitis  humeri."  He  has  had  three  months'  ])ain  in  right  upper 
arm,  at  times  sharp;  occasionally  it  shifts  to  the  elbow  or  forearm.  Day 
and  night  make  no  difference. 

One  month  ago  it  began  to  swell  and  the  soreness  and  tenderness 
increased.     Otherwise  he  feels  well. 

Examination. — Whole  ui:)per  right  arm  2}  inches  larger  in  circum- 
ference than  the  left.  Hard  (bony?)  enlargement  is  felt  beneath  the 
muscles.     The  whole  mass  is  Jwt  and  tender. 

A  y)lexus  of  ^•eins  is  jjromincnt  over  up])er  inner  side  of  the  arm. 

Discussion. — The  fact  of  enlargement  of  the  ui)per  arm  f)elo\v 
the  shoulder  and  at  the  ])oint  of  ])ain  excludes  many  of  the  conditions 
discussed  in  previous  cases.  Sul^a.c.rQniial  bursitis,  artliriti-^  of  the 
shoulder-joint,  circumtlex  ])aral}"sis.  brachial  neuritis,  tuberculous 
disease  without  abscess  formation  'caries  sicca),  all  ])roduce  ^tro])hy, 
£ipt  enlargement. 

The  heat  and  tenderness  dispose  us  to  consider  a  sejitic  osteomye- 
litis, a  i)eriostitis,  or  a  tuljerculosis  with  abscess  and  infiltration  of  the 


PAIN    IN    THE    ARMS 


339 


overlying  tissues,  but  in  such  diseases  one  would  expect  fluctuation 
rather  than  such  extreme  induration.  Rarely,  moreover,  does  an  osteo- 
myelitis or  periostitis  result  in  enlargement  of  the  superficial  veins. 

Syphilitic  disease  of  the  bone,  or  gumma  involving  the  skin,  would 
probably  produce  far  less  pain  and  little  or  no  enlargement.  After 
three  months'  duration  there  would  almost  certainly  be  some  involve- 
ment of  the  skin,  some  discoloration  or  ulceration. 

The  enlargement  of  the  veins  associated  with  an  increase  in  the  size 
of  the  whole  arm,  with  marked  induration,  is  very  characteristic  of 
malignant  disease  involving  the  bone. 

Outcome. — A'-ray  examination  showed  only  a  slight  increase  in  the 
area  of  bone-shadow — apparently  a  periostitis.  The  Wassermann 
reaction  was  negative.     Operation  showed  osteosarcoma. 

Diagnosis. — Sarcoma  humeri. 

Case  173 

A  school-ljoy  of  twelve  was  struck  on  tlie  right  arm  just  l^elow  the 
shoulder  eight  weeks  ago.  The  arm  ])ecame  at  once  swollen,  and  in  the 
])ast  few  wec^<s  has  been  so  ])ainful  as  to  require  morphin,  especially  at 

night. 

Kxauiifialion. — A  swelling  one-half  the  size  of  an  orang^e  occupies  tlie 
deltoid  region,  and  extends  one-third  of  the  way  down  tb.e  arm,  about 
half  encircling  it.  The  shoulder  motions  are  free  and  painless.  The 
\'eins  over  the  lower  ])()rti()n  of  it  are  enl;irged.  The  niiiss  is  rather 
soft,  \ery  tender,  and  ;ipi)arentl}'  adherent  to  the  l)one.  <  )ne  enLirged. 
non-tender  gland  is  felt  in  tlie  riglit  axilla  (normal  microscojiic;'.!!}- '. 

Discussion.  -The  acute  sv.elling  iuid  pain  near  the  IhtuI  of  the 
humerus  are  rather  cliaracteristic  of  septic  osteomyt'htis.  opeeiall}'  ii: 
a  boy  of  this  age.  Hut  iii  tlu-  course  of  eildit  weeks  op.e  would  r:'t!ier 
expect  that  the  ])us  would  ha\"e  Inirrowed  to  tlie  surkiee  or  I)rou!iht 
about  a  general  septieenda. 

Mx|)tTts  ill  legerdemaiii  aeeoin]>lisli  iht'ir  tricks  1)\'  selling  a  trap 
for  our  attention  and  altraeting  our  ga/.e  to  the  wrong  place  al  the  wrong 
tiinc'.  P)y  a  similar  pswh.oloiric  Tiieclianisni  a  histor\-  of  iniu''\'  like 
this  beeoi";ns  one  of  the  eonimonc'st  and  most  dangero'.;^  ot  Ir.ips  -;'i  in 
eateh  un\'.;,r\-  diagnostic  k;ns.  Our  allenlion  g;'t>  I'oncenira.it'd  "'">i 
a  '.'roup  ol  lesions,  such  as  dislocation.  I'ra.eture,  liemaloma.  or  \)".v^\\\-. 
■>".  Idch  niiLdil  result  direclh'  tVoin  trauma.  While  \' e  are  pu.;di!v;  1< 
decide  between  thc'se  alternatixes.  or  perliaps  eariwnv  o'.n  li-ea'ineiil 
designed  to  reliexc  one  of  ik.em,   ine   actual   b:!l   i;nr-'i>"e(  !ed   neoiikisin 


340  DIFFERENTIAL   DIAGNOSIS 

or  tuberculosis  progresses  without  hindrance.  We  forget  for  the  moment 
that  osteosarcoma  is  common  in  this  situation  and  at  this  age. 

The  plexus  of  swollen  veins  over  the  swelling  is  rather  suggestive  of 
tumor,  but  against  it,  apparently,  is  the  normal  microscopic  structure 
of  the  enlarged  axillary  glands,  which  one  would  expect  to  find  trans- 
formed as  a  result  of  metastasis  from  the  bone  tumor.  It  must  always 
be  rememl)ered,  however,  that  the  examination  of  a  gland  under  condi- 
tions like  these  sometimes  proves  very  misleading.  Twice  I  have 
known  malignant  disease  of  the  mediastinum  associated  with  a  large 
axillary  gland,  which,  when  removed,  showed  nothing  abnormal  in  its 
structure.  Diagnostic  conclusions  from  the  examination  of  glands  in  tJie 
neighborhood  of  doubtful  lesions  are  of  value  only  when  the  results  of 
examination  are  positive.  Negative  results  are  valueless,  as  was,  indeed, 
exemj)lified  in  this  case  by  the  outcome. 

Outcome. — Incision  allowed  the  escape  of  some  soft  material 
resembling  grains  of  sago.  On  microscopic  examination  these  grains 
showed  the  structure  of  round-cell  sarcoma. 

Diagnosis. — Sarcoma  humeri. 

Case  174 

A  boy  of  ten  was  sent  to  the  hospital  for  a  tumor  of  the  humerus. 

One  month's  pain  in  the  right  upper  arm,  with  subsequent  gradual 
swelling  but  no  tenderness,  was  the  gist  of  his  history. 

Two  weeks  ago  the  pain  became  severe.     No  known  cause. 

Examination. — Looks  w^orn  out.  Right  forearm  and  up])er  arm 
swollen  (radial  pulse  good).  Motions  free.  The  lower  half  of  the 
humerus  is  tender. 

Discussion. — The  boy  is  at  the  age  when  septic  osteomyelitis  or 
malignant  tumors  are  apt  to  attack  the  end  of  the  long  bones.  The  worn- 
out  appearance  of  the  boy  and  the  absence  of  tenderness  rather  favor 
tumor,  but  it  is  to  be  noted  that  tenderness  is  absent  only  in  the  upper 
part  of  the  arm,  while  the  lower  j)art  is  notably  sensitive. 

Why  is  the  whole  arm  swollen?  We  have  no  e\'idence  of  pressure  from 
tumor,  aneurysm,  or  cervical  rib,  no  sign  of  phlebitis  or  cellulitis.  Such 
a  swelling  would  be  very  unusual  were  we  dealing  with  tuberculous 
osteomyelitis. 

It  does  not  appear  that  the  diagnosis  can  be  made  any  clearer  with- 
out x-ray  exidcnce  or  o])eration.  To  these  procedures,  accordingly, 
we  must  turn. 

Outcome. — A^-ray  shows  thickened  |)eriosteum  over  a  swollen 
humerus  with  a  dark  area  in  the  middle  of  the  lower  one-third  of  the 


PAIN    IN    THE   ARMS 


341 


bone.  Three  ounces  of  pus  were  e\acuated  from  a  cavity  in  the  medul- 
lary portion  overlain  by  thickened  bone  and  periosteum.  Staphylococci 
in  pure  culture  from  the  pus.     Temperature,  99°  to  100°  F. 

Well  in  a  week. 

Diagnosis. — Septic  osteomyelitis. 

Case  175 

A  hardwood  finisher  of  forty-seven  fell  down  stairs  in  1901,  striking 
the  right  shoulder  and  the  back  of  the  neck.  For  three  months  after 
this  the  shoulder  continued  sore. 

In  1903  he  began  to  have  attacks  of  sharp  ])ain  between  his  shoulders, 
disabling  him  from  work  for  several  weeks  at  a  time,  not  relieved  by 
any  medicine. 

In  September,  1904,  jmin  in  the  naj)e  troubled  him  and  continued 
until  January,  1905.  In  December,  1904,  the  pain  between  the  shoulders 
and  in  the  right  shoulder  became  severe  again,  and  has  lasted  until  the 
present  time  (January  17,  1905).  This  pain  is  not  affected  by  motion 
or  position,  but  often  keeps  him  awake  at  night. 

Cough  with  ])rofuse  white  sputa,  two  months.  The  cough  produces 
an  increase  of  pain  in  the  right  shoulder  and  at  the  root  of  the  neck  in 
front. 

Has  lost  20  j)ounds  in  two  years. 

Examination. — Left  jjupil  larger  than  the  right.  The  j)atient  stands 
with  a  well-marked  stoop.  An  impulse  lifts  the  manubrium  with  each 
heart-beat.  A  diastolic  murmur,  loudest  in  the  second  right  space,  is 
audible  over  the  whole  heart,  which  shows  no  ob\ious  enlargement. 
The  pulse  collapses  markedly.  The  larynx  and  trachea  are  normal. 
There  are  dulness,  tenderness,  bronchial  breathing,  and  increased  voice- 
sounds  at  the  right  apex.  The  right  cla^■iclc  and  shoulder  arc  tender  to 
touch,  but  all  motions  are  free.  There  is  no  muscular  atrophy.  Physi- 
cal examination  is  otherwise  negati\e. 

Discussion. — The  history  of  the  case  naturally  suggests  that  the 
present  symptoms  are  due  to  trauma.  esj)ecially  as  the  shoulder  is  -till 
tender.  But  a  more  careful  reading  shows  that  the  inter\al  between 
1901  and  1903  is  too  long  for  any  such  explanation. 

Apparently  there  is  no  lesion  of  the  joint,  muscle,  or  ner\e.  All 
articular  motions  are  free;  muscular  action  does  not  inerea>e  the  I'ain. 
and  the  suffering  is  not  detlnitely  localized  along  any  ner\e  trunk. 

The  long-continued  cough  (two  month^V  the  emaciation.  [\)v  ab- 
normal physical  signs  at  the  right  apex,  and  the  ehe-t  I'ain  had  led  to 
a   diagnosis   of   pulmonary    tul)erculo-i-    by    the    attending:    I'hysician. 


342 


DIFFERENTIAL   DIAGNOSIS 


But  there  seems  to  be  no  fever,  no  evidence  of  breaking  down  within 
the  lung  (rales,  purulent  sputa),  and  a  great  deal  more  pain  in  the 
shoulder  than  one  expects  to  see  in  phthisis.  Especially  notable  in  this 
respect  is  the  long  duration  of  pain  before  the  cough  began.  There 
seem  to  have  been  nearly  two  years  of  suffering  before  there  was  any 
cough. 

By  some  orthopedic  specialists  many  pains  in  the  back,  shoulders, 
and  arms  are  explained  by  the  so-called  "round-shoulder  deformity" 
— the  ordinary  stooping  habit.  Up  to  date  I  have  not  been  convinced  of 
the  validity  of  these  explanations.  The  difficulty  with  all  such  explana- 
tions is  that  they  fail  to  show  why  the  stoop  has  persisted  so  many  years 
longer  than  the  pain  supposed  to  be  due  to  it.  In  any  case  it  is  not  at 
all  probable  that  a  stoop  will  be  advanced  to  explain  such  severe  and 
definitely  localized  pain  as  is  here  complained  of. 

This  patient's  pain  is  in  a  very  queer  place.  One  very  seldom 
hears  patients  complain  of  pain  high  up  between  the  shoulder^  and  when- 
ever one  hears  such  complaints,  some  cause  of  intrathoracic  j^ressure 
should  be  suspected.  Such  causes  are,  for  practical  purposes,  three  and 
only  three,  viz.,  aneurysm,  vertebral  tuberculosis,  and  malignant  disease. 
Turning  now  to  the  circulatory  system  with  the  thought  of  aneurysm  in 
mind,  we  note  that  there  is  evidence  of  aortic  regurgitation,  such  as 
often  accompanies  aneurysm.  We  notice  also  the  inequality  of^jjie 
pupils,  and  we  are  led  thus  to  suspect  that  the  pulmonary  lesions  may  be 
the  result  of  pressure  upon  the  lung  itself  or  upon  one  of  the  larger 
bronchi.  Obviously,  this  possibility — -aneurysm —has  much  in  its  favor, 
especially  when  we  consider  the  long  duration  of  the  symptoms.  Intra- 
thoracic neoplasm  would  probably  have  produced  more  obvious  and 
alarming  symptoms  if  it  had  existed  so  long.  Tuberculous  or 
other  disease  of  the  cer\ical  or  upper  dorsal  vertd^rcC  should  pro- 
duce some  stiffness  or  tenderness  of  the  spine,  and  after  so  long  a  course 
some  evidences  of  caseation,  telescoping,  kyphos,  or  fever  would  be 
expected. 

Outcome. — A'-ray  shows  an  extensive  shadow  to  the  left  of  the  ster- 
num. Had  in  the  ward  several  attacks  of  severe  ]^recordial  pain,  with 
great  anxiety,  relieved  by  nitroglycerin.  Pain  then  ceased  for  th'c 
weeks. 

In  March,  1905,  he  ])egan  to  have  pain  in  the  top  of  the  right  shoulder, 
with  a  scalding  feeling  in  the  arm  above  the  elbow. 

The  heart  a])ex  was  then  found  to  be  in  the  sixth  space,  six  inclies 
to  the  left  of  the  median  line.  The  right  pulse  is  smaller  than  the  left, 
and  of  "Corrigan"  ty])e.     Tracheal  tug.     The  patient  remained  in  the 


PAIN    IN    THE   ARMS 


343 


hospital  until  April  6th,  suffering  very  little  pain.     His  treatment  con- 
sisted of  j)otassium  iodid,  aspirin,  and  laxatives. 
Diagnosis.— Thoracic  aneurysm. 


Case  176 

A  cook,  tifty-nine  years  old,  colored,  born  in  Martinique,  entered  the 
hospital  March  28,  1908.  He  has  always  been  well  exce])t  for  "rheu- 
matism" many  years  ago,  which  attacked  many  joints  but  did  not  keej) 
him  in  bed.     He  denies  venereal  disease. 

For  two  years  he  has  had  attacks  of  pain  in  the  left  shoulder,  radiat- 
ing thence  to  the  breast-bone  and  to  the  pit  of  the  stomach.  These 
attacks  of  pain  have  come  at  considerable  intervals  until  within  the  past 
two  weeks,  when  they  have  come  every  other  day,  and  ha\e  forced  him 
to  stop  work.  The  pain  is  not  severe,  and  is  always  reliex'ed  by  rest  -or 
drinking  hot  water.  He  says  that  his  left  arm  is  weak,  especially  after  an 
attack  of  pain.  His  ankles  have  been  painful  and  swollen  for  two  weeks, 
and  he  has  had  a  hacking  cough  for  li\e  months.  At  one  lime  he  noticed 
that  he  passed  more  urine  at  niglit  than  in  the  day-time,  but  this  is  not 
now  the  case. 

His  appetite  is  good;  he  has  no  indigestion  and  no  headache. 

On  physical  examination  the  i)ainful  shoulder  showed  no  objective 
abnormalities.  The  cardiac  a])ex  seemed  to  extend  one  inch  outside  the 
nijj|)le-line  in  the  fifth  space.  A  systolic  murmur  was  heard  at  the  base 
and  down  to  the  fourth  left  s|)ace.  The  aortic  second  sound  was  faint, 
the  ])ulmonic  second  sound  somewhat  louder,  but  not  accentuated. 
The  ))ulses  seemed  to  be  of  high  tension,  but  the  l)lood- pressure  read 
only  T  :;8  mm.  of  mercury.  The  radials  and  Ijrachials  were  markedly 
thickened  and  tortuous.  The  edge  of  the  li\er  was  felt  two  inches  below 
the  ensiform.  In  tlie  fourth  left  interspace,  near  the  sternum,  a  faint 
diastolic  murmur  was  later  made  out.  At  no  time  was  there  any  ca])inar\" 
pulse  or  Corrigan  ]>ulse.     A'~niy  was  negati\'e. 

Discussion.  —We  may  exchide  all  varieties  of  arthritis  (rheumatic 
and  other),  because  the  joints  are  at  present  normal.  Muscular, 
])eri()steal,  and  nerve  lesions  can  be  ruled  out  by  the  al)sence  of  swelling, 
tenderness,  and  heat,  the  absence  of  anv  relation  of  the  ])ain  to  muscular 
movements  or  to  the  anatomic  position  of  the  ner\e.  Then-  is  no 
important  evidence  pointing  to  aii\'  source  of  pressure  within  tlu'  elioi. 

When  these  possibilities  are  excluded,  we  note  that  tlu-  pain  conies 
in  paro.wsms  which  are  relieN'ed  bv  rest,  and  that  it  lia>  \er}  \\i(ie 
radiations.     An_\'   i)ain   of   this   tvpe   occurring   in   a    man   ol    litl}'  nine 


344 


DIFFERENTIAL   DIAGNOSIS 


suggests  aneurysm  or  angina  pectoris,  especially  if  the  patient  is  a 
negro.  Of  aneurysm  we  have  no  definite  evidence,  though  it  cannot 
be  ruled  out  without  x-ray  examination.  Most  cases  of  angina  pec- 
toris are  associated  with  a  greater  elevation  of  the  blood-pressure,  but 
the  disease  cannot  be  ruled  out  on  that  account.  Angina  is,  there- 
fore, the  most  reasonable  diagnosis.  Greater  certainty  can  be  attained 
through  the  therapeutic  test,  but  only  time  can  exclude  aneurysm. 

Outcome.— The  patient  was  given  5  grains  of  potassium  iodid 
three  times  a  day,  with  y^^  grain  nitroglycerin  and  cascara  as  needed; 
later,  15  minims  of  tincture  of  digitalis  three  times  a  day  were  added. 

By  April  4th  he  had  made  marked  improvement,  and  was  sleeping 
soundly  every  night.  On  April  5th  he  was  out  of  bed,  and  thereafter 
was  almost  free  from  symptoms  until  his  discharge  on  the  eleventh. 

This  case  is  introduced  as  an  example  of  a  somewhat  unusual  dis- 
tribution of  pain  in  angina  pectoris.  In  other  cases  the  pain  may  be 
wholly  epigastric,  w^hoUy  or  largely  in  the  arms  or  in  the  back.  We 
are  justified  in  grouping  all  these  widely  separated  pains  under  the 
single  heading  of  "angina,"  because  all  of  them  are  associated  with 
arteriosclerosis  and  wdth  cardiac  disease  which  is  fairly  well  compen- 
sated. It  is  important  that  all  of  them  are  produced  and  relieved  in 
the  same  way.  The  four  specially  characteristic  occasions  for  anginal 
pain  are  all  of  them  occasions  of  suddenly  raised  blood- pressure.  These 
are: 

(a)  Muscular  exertion. 

(b)  Strong  emotion. 

(c)  Digestion,  especially  if  it  be  impeded  in  any  way. 

(d)  Getting  up  in  the  morning. 

The  vast  majority  of  anginal  attacks  are  produced  by  one  of  these 
four  causes,  which  I  have  arranged  in  the  order  of  their  frequency. 
Much  less  common  is  angina  that  wakes  the  patient  from  sleep.  The 
relief  of  pain  when  one  of  these  causes  has  been  removed  usually  enables 
the  patient  and  his  physician  to  be  quite  clear  as  to  its  cause.  The 
relief  by  some  one  of  the  nitrite  preparations,  which  tend  to  lower 
blood-pressure,  is  also  of  great  diagnostic  value. 

Diagnosis. — Angina  pectoris  [syphilitic  aortitis?]. 

Case  177 

A  tailor  of  sixty  entered  the  hospital  July  21,  1906.  He  stated 
that  for  eight  or  nine  weeks  he  had  had  rheumatism  in  his  right  shoulder, 
which  is  now  much  better  and  troubles  him  very  little.  A  little  later 
he  noticed  a  lump  just  above  and  to  the  right  of  his  breast-bone.     This 


PAIN   IN    THE   ARMS 


345 


has  gradually  increased  in  size  until  the  last  week,  when  it  has  grown 
very  rapidly.  It  is  hard,  not  tender,  and  seems  to  "beat."  He  now 
notices  pain  on  lifting  his  right  arm  or  turning  on  his  right  side.  There 
is  no  history  of  injury.     For  the  past  two  months  he  has  been  hoarse. 

Physical  examination  shows  that  the  pupils  are  equal  and  react 
normally,  though  they  are  slightly  irregular.  The  heart  shows  nothing 
abnormal.  To  the  right  of  the  sternum,  above  the  second  rib,  is  found 
an  expansile,  pulsating  tumor,  the  size  and  shape  of  an  egg.  The 
right  clavicle  is  pushed  forward,  and  the  sternal  end  seems  to  be  buried 
in  the  tumor.  The  manubrium  is  eroded  and  the  first  rib  completely 
cut  off  from  the  sternum.  There  is  no  dulness  beneath  the  manubrium, 
and  no  other  abnormal  pulsation.  There  is  a  faint  systolic  murmur 
over  the  tumor. 

Physical  examination  of  the  lungs,  abdomen,  extremities,  blood, 
and  urine  is  otherwise  normal. 

Discussion. — Hoarseness,  shoulder  pain,  irregular  pupils,  and  a 
pulsating  lump  near  the  breast-bone  seem  at  first  almost  indisjnitable 
evidence  of  aneurysm,  and  so,  in  fact,  they  did  seem  to  most  of  those 
who  saw  this  case  in  the  hospital  wards.  Certain  points,  howe\er, 
were,  at  any  rate,  atypical,  to  wit: 

(a)  The  pain:  why  should  it  decrease?  It  rarely  does  decrease 
in  cases  of  aneurysm  unless  the  patient  takes  to  bed  and  adopts  other 
measures  for  slowing  the  circulation. 

(b)  The  j)ercussion  area:  why  should  there  be  no  substernal  dul- 
ness? The  aneurysm  must  be  su|)posed  to  arise  from  the  arch  of  the 
aorta,  and  ought,  therefore,  to  produce  dulness  under  the  manubrium. 

(c)  Aneurysms  rarely  begin  above  the  level  of  the  sternum  in  the 
neck  or  behind  the  clavicle.  Unusual  pulsations  at  this  j)oint  rarely 
turn  out  to  be  aneurysm. 

(//)  The  ])atient  is  rather  old  for  aneurysm,  though  this  by  no  means 
excludes  it. 

(c)  An  aneurysm  situated  in  this  position  would  ]jr()l)al)ly  invohe 
the  subclavian  artery  or  the  innominate  sufficiently  to  j^roduce  ineciuality 
of  the  pulses. 

Decisive  evidence  might  j)robably  have  been  obtained  by  .v  ray 
examination. 

If  not  aneurysm,  what  else  could  this  lump  be?  Giimmalous  tumors 
a^-e  common  in  this  situation.  They  are  not  usually  painful  and  destroy 
much  less  bone  than  aj)pears  to  have  disaj)peare<l  in  this  case.  'Jluy 
])ulsate  only  in  case  they  ha\e  ])erforated  the  sternum,  which  is  a  rare 
cxTurrence. 


346  DIFFERENTIAL    DIAGNOSIS 

Tuberculosis  of  the  bones  composing  the  thoracic  wall  usually  shows 
more  evidence  of  caseation,  produces  but  little  pain  and  that  confined 
to  the  diseased  focus  itself,  and  never  pushes  the  clavicle  forward. 

Malignant  disease  originating  in  the  ribs,  in  the  sternum,  or  in  some 
of  the  mediastinal  structures  would  produce  most  of  the  signs  here 
described.  The  marked  pulsation  seems  less  inconsistent  with  a  vascular 
neo])lasm  than  with  syphilis  or  tuberculosis.  The  patient's  age  is  sug- 
gesti\-e  of  neoplasm  rather  than  of  aneurysm. 

Outcome. — Despite  the  considerations  just  adduced,  a  diagnosis 
of  aneurysm  was  made.  The  patient  left  the  hospital  on  the  twenty- 
fifth  of  July,  and  not  long  after  consulted  Dr.  Maurice  H.  Richardson, 
who  removed  an  incapsulated  \'ascular  tumor  which  suggested,  on 
histologic  examination,  a  metastasis  from  hypernephroma.  There 
was  no  aneurysm.  Some  months  later  the  patient  entered  the  Cam- 
bridge Hospital  for  profuse  renal  hemorrhage,  probably  due  to  the 
primary  tumor. 

Diagnosis. — Metastatic  hyj)ernephroma. 

Case  178 

A  milliner  of  twenty-seven  entered  the  hospital  March  9,  1907. 
Her  family  history  was  negative,  and  she  remembered  no  illness  until 
within  the  past  year,  when  she  has  had  dysentery  with  eructations  of  gas 
after  eating,  especially  after  taking  fried  food.  She  has  had  to  get  up 
to  pass  water  once  or  twice  at  night  for  the  past  year.  For  two  months 
she  has  been  conscious  of  her  heart-beat.  P^ighteen  months  ago  she 
weighed  112  pounds,  which  was  about  her  average  weight.  Now  she 
weighs  97  pounds. 

Three  months  ago  she  began  to  have  cough,  which  sometimes  is  so 
intense  as  to  make  her  \omit.  She  spits  almost  nothing.  For  the  same 
yjeriod  she  has  noticed  shortness  of  breath  on  slight  exertion.  January 
30,  1907,  she  was  admitted  to  the  Rutland  Sanatorium  for  tuberculosis, 
and  five  examinations  of  her  sputa  were  made,  with  negati\'e  results. 
Her  temperature  while  there  was  normal  the  greater  ])art  of  the  time,  but 
at  irregular  intervals  it  would  rise  to  100°  or  100.5°  F.  She  comes  to 
the  hospital  directly  from  Rutland.  On  more  careful  f[uestioning  she 
admits  that  for  a  }-ear  slic  has  been  having  dull  pains  in  the  left  side 
of  her  neck,  and  ])ain  and  numbness  in  the  left  arm.  This  pain  is  apt 
to  increase  gradually  for  t\\o  or  three  minutes  and  then  suddenly  sto|). 
Kggnog  or  anything  containing  alcohol  makes  the  pain  distinctly  worse. 
It  has  C{uite  frequently  kept  her  awake  at  night.  Lying  on  the  left  side 
makes  it  worse. 


PAIN    IN    THE    ARMS 


34; 


Physical  examination  shows  slight  brownish  pigmentation  of  the  skin. 
The  left  chest  is  somewhat  fuller  in  front  than  the  right,  and  the  veins 
over  it  are  prominent.  Over  the  left  clavicle  is  a  small  mass  the  size 
of  an  English  walnut,  hard  and  movable,  not  tender.  The  heart  is 
negative.  The  left  lung  shows  dulness  just  above  and  below  the  clavicle. 
Throughout  the  left  front,  breathing  is  distant,  and  the  same  is  true  of 
the  left  back  below  the  scapula,  where  there  is  dulness  and  diminished 
fremitus  as  well.  The  abdomen  is  negative.  The  left  u])per  arm 
measures  21  centimeters;  the  right,  9  centimeters. 

Discussion. — ^The  mistaken  diagnosis  of  tuberculosis  was  quite 
excusable  in  this  case.  Cough,  dyspnea,  pain,  with  dulness  at  one  pul- 
monary apex,  loss  of  weight,  and  a  slight  pyrexia  are  certainly  ver}- 
strong  evidence  in  favor  of  tuberculous  infiltration.  It  was  only  after 
repeated  negative  examinations  of  the  sputa  that  it  seemed  necessar}'  to 
reconsider  the  diagnosis.  The  fact  that  no  rales  had  a])])eared  during 
a  considerable  period  of  oliservation,  and  especially  the  early  appearance 
and  long  persistence  of  ])ain,  began  to  make  it  seem  likely  that  some 
deeper  and  more  serious  disease  was  at  work. 

The  most  significant  fact  in  this  case  is,  1  think,  the  long  inter\al 
(nine  months)  between  the  beginning  of  pain  sufficient  to  keep  her 
awake  and  the  onset  of  cough.  This,  1  think,  should  have  made  us 
susjMcious  and  doubtful  of  our  diagnosis  from  the  first. 

High  Pott's  disease  must  be  reckoned  with.  There  need  be  no 
kyphos  in  sucR  cases,  and  the  ])ain  is  often  referred  to  ])oints  distant 
from  the  s]jinal  lesion.  The  ])ain,  however,  is  the  only  symptom  which 
points  toward  vertebral  tuberculosis.  We  have  no  muscular  s]xism,  no 
stiffness  or  torticollis,  none  of  the  evidences  of  caseation  or  abscess 
formation  sucii  as  might  well  be  exjjected  after  a  year's  duration  of  the 
disease. 

W'licn  the  arm  l)egan  to  swell  and  the  lump  a])])eared  abo\e  the  left 
cla\icle,  there  was  no  longer  any  considerable  doubt  that  a  mediastinal 
tumor  of  some  type  was  ])ressing  upon  the  brachial  ])lexus.  Siuli 
tumors,  whether  they  arise  from  mediastinal  glands,  froni  the  root  ot 
the  lung,  or  from  the  pleura,  usually  l>('ij;iu  unlh  symptoms  of  oni'nuiry 
pleural  cfjusion,  for  which  they  are  fre(|uenlly  mistaken.  In  their  earl\' 
stages  there  are  often  no  ])ain,  no  external  tumor,  and  no  swelling  of  the 
arm.  The  pleural  effusion,  howexer,  reaccumulatcs  with  astonishinLr 
swiftness  after  aspiration.  It  nia\"  or  niav  not  be  bloodw  and  its  cellular 
constituents  ma\'  or  niav  not  i)e  identical  with  those  of  ordinar\  itiihtr 
culous)  pkniris\'.  But  it  is  especiallv  the  rai)i(l  refilling  of  the  c'he>i  attrr 
tap})ing  that  finalh"  awakens  our  sus])icions  of  malignanl  diseasr. 


348  DIFFERENTIAL  DIAGNOSIS 

Outcome. — X-ray  of  the  chest  showed  a  diffuse  shadow,  chiefly  on 
the  left  side,  but  extending  also  a  short  distance  to  the  right  of  the  spinal 
column.  The  nodule  at  the  base  of  the  neck  was  removed  and  examined 
by  Dr.  Wright,  who  pronounced  it  malignant  lymphoma.  The  evidences 
of  fluid  at  the  base  of  the  lung  steadily  increased.  The  patient  did  not 
react  to  3.5  mgm.  tuberculin.  On  the  twenty-fourth  of  March  she 
was  discharged  not  relieved. 

Diagnosis. — Malignant  lymphoma. 


PAIN   IN   THE   ARMS 


349 


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CHAPTER  XII 
PAIN   IN  THE  LEGS  AND  FEET 

Case  179 

A  HACKMANof  twentv-fixe  entered  the  hospital  March  6,  1907.  His 
family  history  was  negative.  A  year  ago  he  had  urethritis  and  was  sick 
for  a  month.  For  a  week  his  left  ankle  was  swollen  and  red  and  he  was 
unable  to  use  it  for  a  month.  Six  days  ago  he  noticed  a  cutting  pain  in 
his  right  hip,  relieved  by  sitting  down.  Four  days  ago  he  was  unable  to 
get  out  of  bed.     Yesterday  his  left  ankle  was  swollen  and  sore. 

Physical  examination  showed  normal  temperature,  pulse,  and  res- 
piration. The  chest  and  abdomen  were  normal.  There  were  slight 
tenderness,  redness,  sweUing,  and  pain  across  the  instep  of  the  left  foot. 
Motions  of  the  right  hip  caused  marked  pain  in  the  sacro-iliac  joint. 
There  was  also  tenderness  there. 

Discussion. — We  are  dealing  with  lesions  of  the  right  hip  and  left 
ankle — in  all  probability  some  type  of  arthritis.  The  diagnosis  of 
rheumatism  must  be  avoided  like  a  blasphemy  unless  we  are  forced  to  it 
by  the  exclusion 'of  all  other  possibilities.  To  those  possibilities  we  will 
accordingly  turn  our  attention. 

Hypertrophic  arthritis  (osteoarthritis)  does  not  attack  these  joints 
in  a  man  of  twenty-five.  It  will  be  rememliered  that  in  the  hi|)-joint 
this  lesion  constitutes  the  malum  coxa  senilis  and  leaves  youngsters 
unscathed. 

Atrophic  arthritis  might  involve  these  joints  in  a  }"Oung  man,  but 
always  in\"oh"es  other  joints  as  well  (particularly  those  of  the  hand),  and 
it  is  very  ])rone  to  a  symmetric  distribution,  e.  g..  Ijoth  wrists,  both 
ring  fingers,  both  hips,  both  feet. 

Were  the  sacro-iliac  joint  alone  affected,  it  might  not  be  necessary 
to  assume  tlie  ])resence  of  any  infiammatory  lesion.  Some  strain  or 
displacement  of  the  joint  might  suffice  to  jjroduce  the  ])ain.  But  since 
the  opposite  ankle-joint  is  also  in\'ol\-ed,  we  have  no  reason  to  connect 
the  two  lesions  mechanical]}-.  Infection  is  the  only  r)tlier  familiar  link. 
es])ecially  as  we  lia\e  no  delinite  e\'idence  of  any  metabolic  defect,  such 
as  "Out. 


Causes  of  Pain  in  Legs  and  Feet 


1.  INFECTIOUS  DISEASES  (AT  ONSET   ESPECIALLY; 


FLAT-FOOT 


TIOUS    I 
"HRITIS  t 


INFECTIOUS 
ARTF 


VARICOSE  VEINS 

TABES 

HYPERTROPHIC) 
ARTHRITIS  )' 

7.  PHLEBITIS 

8.  SCIATICA 

9.  OSTEOMYELITIS 

10.  TUBERCULOSIS 

11.  SPRAINED  ANKLE 

12.  SPRAINED   KNEE 

13.  SYPHILITIC         ) 

PERIOSTITIS  i 

14.  ATROPHIC       1 

ARTHRITIS  I 

15.  TENOSYNOVITIS 
16. 


17. 


ALCOHOLIC  ) 
NEURITIS  t 

SARCOMA    OF     LEG) 
BONES  t 


18.  GOUT 
19 


20. 


MORTON'S      META-) 
TARSALGIA  i 

INTERMITTENT      1 
CLAUDICATION  ( 


2204 
789 

513 

313 

265 

205 
157 
136 
134 
130 
56 

46 

44 
33 
29 


16 


14 


PAIN   IN   THE   LEGS   AND   FEET 


353 


If  the  joint  troubles  are  of  infectious  origin,  the  first  question  to 
be  answered  is:  Could  a  urethritis  last  so  long?  Can  the  joint  trouble 
be  due  to  a  gonorrheal  infection?  To  answer  this  question  we  must 
investigate  the  urethra. 

Outcome. — A  urethral  smear  showed  gonococci.  Vaccines  were 
given  beginning  March  8th,  and  within  two  days  were  followed  by 
considerable  improvement. 

On  the  seventeenth  there  was  much  pain  in  the  sacro-iliac  region, 
and  this  lasted  until  the  twenty-second,  after  which  he  improved  rapidly. 
The  opsonic  index  was  low  most  of  the  time  until  the  twenty-eighth, 


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Fig.  58. — Chart  of  t  asc  1 79.  The  ujtpermost  Hne  represents  the  tem])crature;  the 
next  is  the  leukocyte  count;  the  third  stands  for  the  opsonic  index,  and  the  fourth  for  the 
dose  of  vaccine. 

after  which  it  rose  and  stayed  high.     Its  variations  are  shown  in  the 
accompanying  chart.     On  April   7th   he  was  walking  about  without 
any  difficulty,  and  on  the  ninth  he  was  discharged  much  relieved. 
Diagnosis. — Gonorrheal  arthritis. 


Case  180 

A  colored  man  of  si.xty-four  entered  the  hospital  July  11,  i()o7. 
His  family  history  is  negative.  He  stated  that  he  almost  died  of  a 
"bad  cold"  at  fifteen,  that  he  had  had  spinal  curvature  since  he  was 
thrown  from  a  horse  at  fourteen.  In  the  eighties  he  was  at  the  Pxiston 
Insane  Asvlum  for  a  time. 


354 


DIFFERENTIAL   DIAGNOSIS 


Since  spring  his  right  hip  has  pained  him,  and  for  the  last  three 
weeks  the  pain  has  been  so  severe  as  to  interfere  with  sleep,  and  when 
he  wakes  there  is  much  pain  and  stiffness  in  both  legs,  though  it  wears 
off  considerably  with  exercise.  Three  weeks  ago  his  feet  were  swollen 
for  some  time.  This  has  now  gone.  He  drinks  much  water  and  usually 
passes  urine  three  or  four  times  at  night.  His  bowels  move  every  day 
or  two,  and  only  with  medicine. 

The  movements  of  the  patient's  pulse,  temperature,  and  respiration 
are  seen  in  the  accompanying  chart.  At  entrance  his  white  cells  were 
7700,  but  a  differential  count  showed  that  90  per  cent,  of  these  were 

polynuclear.  There  was  no  anemia.  The 
spine  showed  scoliosis,  resulting  in  a  marked 
prominence  of  the  ribs  of  the  left  back. 
There  was  an  old  bony  deformity  of  the 
right  elbow-joint,  which  was  stiff.  He  was 
poorly  nourished.  There  was  marked  arcus 
senilis.  The  heart  showed  nothing  of  in- 
terest. The  radial  arteries  were  tortuous 
and  stiff.  The  front  of  the  chest  was  nega- 
tive except  for  a  few  fine  rales  over  the  right 
clavicle.  Behind,  the  right  chest  was  dull 
below  the  spine  of  the  scapula,  with  dimin- 
ished or  absent  breathing;  the  left  back  was 
full  of  moist  rales.  The  abdomen  showed 
slight  tenderness  in  the  region  of  the  gall- 
bladder. There  were  glands  the  size  of 
walnuts  or  almonds  in  the  groins,  axillae, 
and  neck.  There  was  practically  no  motion 
in  the  spine.  The  urine  averaged  about  35  ounces  during  his  stay  in 
the  hospital,  with  a  specific  gravity  of  1015,  a  slight  trace  of  albumin, 
and  very  many  hyaline  and  fine  granular  casts,  with  cells  adherent, 
some  of  which  were  fatty. 

On  the  fourteenth  the  chest  was  tapped  and  27  ounces  of  fluid 
removed,  with  a  specific  gravity  of  1015,  albumin,  2  per  cent.,  lym- 
phocytes, 81  per  cent.     The  sputa  showed  nothing  remarkable. 

From  the  seventeenth  of  July  until  the  twentieth  he  was  delirious. 
Discussion. — There  appear  to  be  many  widely  diverging  clues  in 
this  case.  The  history  gives  us  hints  of  psychic  stigmata,  of  tuberculosis, 
of  renal  or  cardiorenal  disease,  of  multiple  arthritis  and  multiple  adeni- 
tis. Certainly  it  is  a  difficult  case  to  untangle.  We  seem  to  have 
reasonably    good    evidence    of    a    chronic    interstitial    nephritis.     The 


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PAIN  IN   THE   LEGS   AND    FEET  355 

nocturia,  the  swollen  feet,  and  the  character  of  the  urine  point  in  this 
direction,  but  it  is  practically  certain  that  he  has  something  else  the 
matter  with  him. 

On  the  other  hand,  that  "bad  cold"  which  he  had  at  fifteen,  follow- 
ing immediately  upon  the  spinal  trouble,  which  appears  to  have  resulted 
in  a  rigid  spine,  makes  us  very  suspicious  of  tuberculosis,  especially 
as  the  symptoms  occur  in  a  colored  man.  The  effusion  in  the  right 
chest  (evidenced  by  dulness  and  absent  respiration)  may  be  due  either 
to  tuberculosis  or  to  mechanical  causes  (dropsy).  The  low  specific 
gravity  inclines  me  to  believe  that  the  fluid  is  not  a  pure  exudate.  The 
multiple  adenitis  is  not  inconsistent  with  tuberculosis,  though  it  might 
also  indicate  syphilis.  All  types  of  leukemia  are  excluded  by  the  blood 
examination. 

That  some  infection  has  invaded  the  patient's  body  seems  indicated 
by  the  continued  fever  and  the  dehrium.  We  might  suppose  that  this  is 
a  terminal  sepsis  due  to  the  streptococcus  or  some  other  of  the  common 
terminal  invaders,  the  rest  of  the  symptoms  being  then  explained  under 
cardiorenal  disease.  But  this  would  not  account  for  the  stiff  spine, 
the  stiff  elbow-joint,  the  general  glandular  enlargement,  and  the  early 
history. 

A  positive  diagnosis  seems  impossible,  but  more  facts  can  be  ac- 
counted for  by  assuming  a  tuberculous  infection  than  by  any  other 
hypothesis.     As  a  matter  of  fact,  however,  this  diagnosis  was  not  made. 

Outcome. — He  became  comatose  on  July  20th  and  on  the  twenty- 
third  he  died. 

Clinical  diagnosis:  Arteriosclerosis;  chronic  nephritis;  pleural  effu- 
sion; terminal  infection.  Autopsy  showed  old  tuberculosis  of  the  spine; 
tuberculosis  of  the  kidneys;  tubercular  ulcer  of  the  ileum;  miliary 
tuberculosis  of  the  bronchial  lymph-glands,  with  suppuration;  tuber- 
culosis of  the  lungs,  liver,  spleen,  kidneys,  and  cpicardium.  The 
guinca-])ig  which  was  inoculated  with  25  minims  of  the  sediment  of  the 
pleural  effusion  was  killed  August  23d  and  showed  no  evidence  of 
tuberculosis. 

Diagnosis. — See  last  paragraph. 

Case  181 

A  housekeeper  of  thirty-one  entered  the  hospital  November  4,  TO07. 
Her  family  history  was  negative.  She  liad  been  operated  upon  at  the 
Massachusetts  (general  Hospital  for  stone  in  tlic  riglu  kidney  in  i»)03, 
but  no  stone  was  found.    All  the  summer  of  njoj  she  had  been  run  down, 


356 


DIFFERENTIAL  DIAGNOSIS 


had  been  easily  nauseated,  and  had  vomited  f requentiy.     The  vomiting 
had  sometimes  been  brought  on  by  worry. 

For  five  weeks  she  has  been  tired,  restless,  and  overemotional. 
Appetite  and  sleep  have  been  poor.  Three  weeks  ago  she  first  noticed 
that  she  limped,  favoring  the  right  leg.  This  limp  has  steadily  in- 
creased, and  for  the  past  two  weeks  she  has  been  constantly  in  bed. 
Two  weeks  ago  she  began  to  have  sharp  pain  in  her  right  groin,  in  the 
right  hip  and  to  some  extent  in  the  right  lower  back.  The  pain  is  worse 
at  night  and  often  keeps  her  awake;  it  comes  in  paroxysms,  leaving  her 
entirely  for  a  few  hours  at  a  time.  When  tired,  she  passes  urine  ev^ery 
two  hours  or  so,  but  she  has  noticed  no  change  in  it.  The  course  of  the 
temperature  is  seen  in  the  accompanying  chart. 

Examination  of  the  chest  was  negative. 
The  abdomen  was  tympanitic  throughout  and 
held  more  rigidly  on  the  left  than  on  the  right. 
On  deep  palpation  there  seemed  to  be  some  ten- 
derness on  the  right.  The  right  leg  was  kept 
continually  flexed  upon  the  body.  Extension  of 
the  hip-joint  or  outward  rotation  was  painful; 
other  motions  were  good.  The  scar  of  the  pre- 
vious operation  w^as  seen  in  the  right  flank.  On 
deep  inspiration  a  rounded,  tender  mass  could  be 
indistinctly  felt  in  the  right  flank. 

Examination  by  an  orthopedic  consultant  con- 
vinced me  that  the  psoas  contraction  was  not  due 
to  any  hip  lesion.  The  kidney  and  the  mesen- 
teric glands  were  suggested  as  possible  causes. 

On  November  5th  and  7th  the  urine  showed 
a  large  amount  of  pus  in  the  sediment;  a  very 
slight  trace  of  albumin;  specific  gravity,  1013;  the 
amount,  about  40  ounces  in  twenty-four  hours. 
Discussion. — In  this  and  the  succeeding  case  we  are  dealing  with 
a  hip  pain  associated  with  a  psoas  spasm.  There  seems  no  evidence  that 
the  hip-joint  or  spine  is  involved.  One  looks  accordingly  for  the  other 
and  less  common  causes  which  lead  to  contraction  of  the  psoas.  Deep 
tenderness  on  the  right  side  of  the  abdomen,  associated  with  fever  and 
psoas  spasm,  is  a  well-known  feature  of  appendicitis.  But  appendicitis 
rarely  begins  with  a  limp  before  there  is  any  right  iliac  pain.  It  should 
produce  some  muscular  spasm  of  the  abdominal  wall,  but  there  is  none  of 
this  here,  nor  is  there  any  localized  tenderness  or  "cake"  over  the 
appendix  region. 


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case  181 


Chart    of 


PAIN   IN   THE  LEGS  AND   FEET  357 

Tuberculosis  of  the  mesenteric  gland  and  occasionally  other  causes 
of  mesenteric  adenitis  may  lead  to  psoas  spasm.  Such  a  diagnosis  is 
hard  to  make,  harder  still  to  deny.  One  inclines  toward  it  if  there  is 
nothing  to  suggest  any  other  recognized  cause  of  psoas  contraction. 
Probably  adenitis  accounts  for  some  of  the  mysterious  cases  of  "idio- 
pathic" or  "hysteric"  spasm  of  the  psoas.  Psychic  causes  are  often 
invoked  when  our  diagnostic  resources  are  exhausted. 

Various  kidney  lesions  (hematogenous  infection,  perinephritic  abscess, 
tuberculosis,  stone)  have  been  known  to  bring  about  a  contraction  of  the 
psoas.  This  patient  has  pus  in  the  urine,  and  an  investigation  of  the 
kidney  is,  therefore,  of  the  first  importance. 

Outcome. — On  November  loth  the  flexion  of  the  leg  had  become 
more  marked.  The  patient  ate  and  slept  poorly.  Three  :x;-ray  plates 
were  taken.     They  showed  apparently  two  renal  stones  on  the  right. 

Operation  November  i6th  showed  two  stones  and  a  little  pus  in  the 
kidney.  Even  under  deep  anesthesia  the  leg  could  not  be  extended, 
but  later,  in  convalescence,  this  spasm  entirely  disappeared  and  she 
walked  well. 

Diagnosis. — Psoas  spasm  due  to  nephrolithiasis. 

Case  182 

An  Italian  hod-carrier  of  thirty-two  entered  the  hospital  June  26, 
1906.  Three  weeks  ago,  while  carrying  bricks  on  a  ladder,  he  felt  a 
peculiar  sensation  in  the  left  hip,  described  as  "throbbing"  (probably 
clonic  spasm).  Since  then  there  has  been  pain  in  the  hip,  with  marked 
stiffness,  the  pain  being  increased  on  motion. 

Visceral  examination  (including  blood  and  urine)  was  negative. 
The  left  thigh  was  partly  flexed,  and  could  not  be  straightened  without 
pain.  Flexion  and  rotation  caused  no  pain.  There  was  no  other 
obvious  spasm  and  no  tenderness.  The  left  groin  was  slightly  fuller 
than  the  right.  X-ray  showed  no  sign  of  hip-joint  disease,  renal  disease, 
or  of  aneurysm,  which  had  been  suggested  by  Dr.  Goldthwait  in  the 
out-patient  department;  although  there  was  greater  pulsation  in  the 
vessels  of  the  afl'ected  side,  the  temperature  in  both  legs  was  the  same. 
There  was  slight  dulness  in  both  flanks,  not  shifting  on  change  of  posi- 
tion. 

Tu])erculin  was  given,  but  no  rise  of  tem})craturc  followed. 

On  July  ist  Dr.  Goldthwait  thought  that  some  fibers  of  the  ilio- 
psoas were  pr()])ably  ruptured. 

Discussion. — In  manv  respects  this  case  resembles  the  last.  In 
studying  it  we  interrogate,  by  means  of  physical  examination — </)  The 


358  DIFFERENTIAL   DIAGNOSIS 

hip-joint;  (b)  the  spinal  column;  (c)  the  appendix  region;  (d)  the  renal 
region  and  the  urine.  We  consider  enlargements  of  the  mesenteric 
glands,  always  so  easy  to  include  and  so  hard  to  exclude  in  cases  of  this 
type.  We  look  for  evidence  of  abdominal  tumors  or  aneurysm  of  the 
aorta. 

In  the  present  case  we  are  able,  apparently,  to  exclude  all  these 
possibilities  except  tabes  mesenterica,  and  this,  in  view  of  the  negative 
tuberculin  reaction,  seems  very  unlikely.  Since  there  is  no  reason  for 
accusing  the  stolid  Italian  laborer  of  the  "vapors,"  we  have  to  fall  back 
upon  a  hypothetic  strain  involving  the  psoas.  There  seems  no  reason, 
a  priori,  why  this  muscle  may  not  be  subject  to  strain  or  sprain  like  any 
other,  but  it  is  obvious  that,  until  we  have  followed  our  patient  far  into 
convalescence,  we  cannot  place  any  reliance  on  such  a  diagnosis. 

Outcome. — By  July  9th  the  patient  was  walking  well,  without  limp 
or  pain.  Uninterrupted  recovery  followed,  apparently  as  the  result  of 
the  magnificent  air  which  he  breathed  in  the  surgical  wards  of  the 
Massachusetts  General  Hospital. 

He  was  given  no  other  treatment. 

Diagnosis. — Psoas  tear  (?). 

Case  183 

A  beef-carrier  of  fifty-three  entered  the  hospital  January  29,  1907. 
His  family  history  is  negative.  He  has  never  been  sick  until  the  present 
illness,  but  has  been  in  the  habit  of  getting  drunk  once  to  three  times  a 
week.  Two  weeks  ago  he  woke  in  the  night  with  a  pain  in  the  right 
hip.  Since  that  time  he  has  been  confined  to  bed  with  pain  and  fever, 
wandering  in  his  mind,  and  constant  twitching  of  the  arms.  His  wife 
says  he  has  had  no  alcohol  for  two  weeks.  He  has  been  treated  for 
lumbago  and  for  diabetes.  Later  it  was  learned  that  five  years  ago  he 
had  had  some  abscesses  on  his  neck  which  discharged  for  a  year.  They 
were  finally  cured  by  an  extensive  operation. 

Physical  examination  showed  good  nutrition,  but  the  patient's 
mind  was  cloudy,  though  he  would  answer  simple  cjuestions.  All  his 
muscles  were  held  rigidly,  especially  those  in  the  neck  and  arms,  but 
there  was  no  paralysis.  The  pupils  were  slightly  irregular,  liut  reacted 
normally.  The  eye  motions  were  normal,  the  chest  and  abdomen 
negative.  The  white  cells  were  13,000;  the  Widal  reaction  suggestive, 
but  not  positive;  the  blood  otherwise  normal,  likewise  the  urine.  Marked 
subsultus  was  the  most  y)rominent  feature.  At  entrance  the  case  was 
taken  for  an  acute  abdominal  emergency  and  immediate  operation  was 


PAIN  IN  THE   LEGS   AND   FEET 


359 


^ 


urged.     On  the  second  day  the  patient  became  unconscious,  with  pro- 
fuse sweating. 

Discussion. — Hip  pain,  fever,  and  dehrium  are  the  presenting 
symptoms.  The  character  of  the  dehrium  suggests  alcohoHsm,  but 
two  weeks'  abstinence  from  alcohol  should  have  steered  him  past  the 
danger  of  delirium  tremens.  The  general  muscular  rigidity,  moreover, 
the  hip  pain,  and  the  irregularity  of  the  pupils  could  not  be 
thus  accounted  for. 

The  mental  condition,  the  muscular  twitchings,  the  fever, 
and  suggestive  Widal  reaction  furnish  us  with  some  of  the 
material  whence  a  diagnosis  of  typhoid  might  be  built  up. 
But  the  leukocyte  count  is  remarkably  high  for  that  dis- 
ease, and  we  should  still  be  left  without  an  explanation  of 
the  hip  pain,  the  muscular  rigidity,  and  the  condition  of 
the  pupils. 

Rigidity  of  the  neck  in  a  febrile  patient  always  makes 
us  fear  meningitis,  and  all  the  other  facts  in  this  case  go  to 
strengthen  this  hypothesis.  If  he  had  been  treated  for  dia- 
betes, as  the  history  states,  he  has  probably  had  sugar  in 
his  urine.  Transient  glycosuria  is  not  uncommon  in 
meningitis  of  any  type. 

But  if  he  has  meningitis,  can  we  in  any  way  explain 
the  hip  pain  ?  Certainly  not  by  the  epidemic  or  aural  t}-pe 
of  meningitis,  but  meningeal  tuberculosis  might  well  origi- 
nate in  a  tubercular  hip,  the  probability  of  which  is  in- 
creased as  we  note  that  he  has  had  chronic  discharging 
abscesses  of  the  neck,  presumably  tuberculous. 

Outcome. — He  died  on  the  thirtieth  of  January.  Auto])sy  showed 
tuljcrculosis  of  the  bodies  of  the  fourth  and  fifth  lumbar  vertebra^  with 
large  ])soas  abscesses;  tubercular  meningitis;  tuberculosis  of  the  retro- 
peritoneal glands;  obsolete  tuberculosis  of  the  left  apex. 

Diagnosis. — Pott's  disease  with  ])soas  abscess.    General  tuberculosis. 


Fig.  6r. — 
Chart  of 
case   183. 


Case  184 

An  architect  of  thirty  entered  the  h()S])ital  May  3,  1907.  His  family 
history,  past  history,  and  hal)its  arc  good.  Five  weeks  ago,  wh.ile 
jum])ing  to  catcli  a  ])ase-ball,  he  felt  a  sharj)  ])ain  in  tlie  left  Jiip.  He 
got  liome  with  difTiculty,  and  has  l)een  in  bed  e\er  since,  suffering 
almost  continual  ])ain  in  the  left  liij)  and  along  the  back  of  tlie  tliii^h. 
0])iates  ha\e  l)een  necessary  to  ])ro(luce  sleej),  and  e\en  then  on!}'  a 
few  hours'  sleej)  at  a  time  lias  been  obtained.     Tlie  pain  has  ne\er  l)een 


360  DIFFERENTIAL  DIAGNOSIS 

in  the  back  and  has  gradually  diminished  in  intensity,  but  the  patient 
is  still  unable  to  walk  or  to  put  the  foot  to  the  ground.  The  left  thigh 
is  held  slightly  flexed,  and  there  is  a  tender  point  two  inches  outward 
and  upward  from  the  tuberosity  of  the  left  ischium.  There  is  also 
tenderness  along  the  course  of  the  sciatic  nerve,  but  none  over  the  sacro- 
iliac joints.  It  was  afterward  learned  that  five  years  ago  he  had  a 
similar  attack,  following  bicycling;  he  was  then  laid  up  for  five  weeks. 
Later  he  brought  on  another  attack  by  jumping  while  playing  tennis. 

Discussion. — As  in  the  previous  case,  the  presenting  symptom  is 
sciatic  pain,  but  here  its  origin  is  not  insidious  and  obscure,  but  abrupt 
and  apparently  traumatic.  In  studying  it  we  must  go  through  the 
same  series  of  investigations  intended  to  bring  to  light  any  cause  for 
pressure  upon  the  nerve  (pelvic  tumors,  bony  outgrowths  from  the 
femur,  spinal  osteoarthritis,  sacro-iliac  displacement)  and  any  metabolic 
disturbance,  such  as  diabetes,  whereby  a  toxic  neuritis  or  neuralgia 
might  arise.  [It  should  be  noticed  in  passing  that  no  one  seems  ade- 
quately to  have  investigated  the  possibility  that  diabetic  sciatica  may 
be  due  not  to  a  chemical  cause,  but  to  muscular  weakness,  destroying 
the  support  of  the  pelvic  articulations.  Certainly  toneless,  flabby  muscles 
play  an  important  part  in  many  cases  of  sacro-iliac  trouble,] 

Many  cases  of  sciatic  pain  seem,  like  the  present  one,  to  begin  after 
an  injury  which  is  usually  of  the  type  here  described,  i.  e.,  a  wrench  such 
as  might  bring  about  violent  extension  of  the  hip-joint  and  possibly 
some  strain  or  stretching  of  the  sciatic  nerve.  It  has  been  more  fre- 
quently assumed,  however,  in  recent  discussions,  that  the  trauma  has 
affected  the  sacro-iliac  joint  primarily,  the  nerve  only  secondarily. 
This  seems  to  me  to  be  a  matter  rather  of  fashion  than  of  reasonable 
conviction. 

Outcome. — X-ray  showed  no  evidence  of  spinal  involvement  or  of 
sacro-iliac  disease,  and  an  orthopedic  consultant  considered  the  case 
one  of  "  simple  sciatica."  From  the  time  of  entrance  until  the  thirteenth 
of  May  he  was  treated,  chiefly  with  a  \iew  to  relieving  the  pain,  by 
means  of  ice-bags,  hypnotics,  and  an  occasional  dose  of  morphin.  On 
the  thirteenth  he  was  given  hydrotherapy  and  Zander  treatment,  which 
within  a  few  days  produced  remarkable  improvement.  On  the  seven- 
teenth he  was  discharged,  much  relieved. 

Diagnosis. — Sciatica. 

Case  185 

A  farm  hand,  thirty  years  old,  entered  the  hospital  February  16,  1907. 
Three  years  ago  he  had  a  compound  fracture  of  the  right  thigh.     He 


PAIN  IN   THE  LEGS   AND    FEET  361 

was  in  bed  seven  months,  and  has  had  half  an  inch  of  shortening  in  that 
leg  ever  since.  After  being  out  of  bed  about  a  month,  he  had  an  attack 
of  what  was  called  "sciatic  rheumatism,"  which,  so  far  as  he  remem- 
bers, was  exactly  like  his  present  illness.  He  was  then  confined  to  bed 
for  two  months  and  was  treated  by  electricity  and  drugs.  He  denies 
venereal  disease,  takes  about  25  cents'  worth  of  beer  and  whisky  a  week, 
and  chews  10  cents'  worth  of  tobacco  a  day. 

Three  days  ago,  without  any  known  cause,  he  felt  a  sharp  pain  in 
the  right  hip-joint.  This  pain  has  continued  ever  since,  is  worse  on 
motion  or  pressure,  radiates  down  the  back  of  the  leg  to  the  ankle, 
and  is  accompanied  by  a  burning  sensation,  also  described  as  like 
electricity.  He  has  never  any  pain  in  his  back.  He  worked  until 
last  night,  but  then  the  pain  was  so  severe  that  he  was  unable  to  sleep, 
even  with  morphin.  This  morning  for  the  first  time  he  noticed  blisters 
on  the  leg,  due,  he  thinks,  to  a  poultice. 

Physical  examination  of  the  chest  and  abdomen  was  negative,  except 
for  a  sausage-shaped  mass  in  the  left  iliac  fossa,  which  disappeared  in 
the  course  of  a  couple  of  days. 

The  knee-jerk  was  very  active  on  the  left,  less  so  on  the  right.  On  the 
left  buttock  was  a  series  of  vesicles  filled  with  straw-colored  fluid.  On  the 
right,  opposite  the  upper  part  of  the  sacrum,  and  over  the  thigh,  in  the 
region  of  the  great  trochanter,  was  a  line  of  ruptured  vesicles.  Pressure 
over  the  sciatic  nerve,  especially  near  its  exit  from  the  pelvis,  in  the  pop- 
liteal space  and  in  the  calf,  was  painful.  Sensibility  was  normal.  There 
was  no  tenderness  over  the  spine  or  pelvic  bones.  Rectal  examination 
was  negative.  The  pain  was  excruciating  in  all  positions,  and  was  ver}- 
little  afi"ected  by  mor})hin.  Ice  at  times  gave  slight  transient  relief. 
After  the  twentv-sccond  the  pain  became  more  bearable,  following 
the  administration  of  three  grains  of  quinin  every  two  hours  until  the 
ears  rang.  Static  electricity  seemed  to  increase  the  pain.  Aspirin  did 
not  help  at  all. 

Discussion. — The  history  of  pain  coming  on  for  the  first  time  soon 
after  a  severe  fracture  of  the  femur  naturally  directs  our  minds  to  the 
possibility  that  l)y  the  callus  formed  at  the  site  of  fracture,  pressure 
may  be  exerted  upon  the  sciatic  nerve  or  adhesions  formed  inAolving  it. 
The  diflficulty  with  this  supposition  is  that  the  ])atient  has  been  free  from 
pain  for  over  two  years,  although  nothing  has  been  done  which  wor.kl 
remove  adhesions  or  alleviate  pressure.  Possibly  there  may  ])e  some  kss 
direct  connection  between  the  fracture  and  the  present  pain,  but  it  is 
difficult  to  get  beyond  the  region  of  conjecture,  (^nlv  by  .v-rav  ixaraina- 
tion  and  rectal  palpation  can  we  get  any  further  e\i(U'nc-i'  in  this  d'.ri'c  tion. 


362  DIFFERENTIAL   DIAGNOSIS 

Any  sciatica  which  involves  both  legs  is  very  suggestive  of  pelvic 
new-growth.  In  this  case  we  have  apparently  a  bilateral  herpetic  erup- 
tion, the  usual  manifestation  of  a  lesion  of  the  ganglion  with  its  corre- 
sponding nerve-root.  The  pain,  however,  is  unilateral,  and  we  have  no 
definite  evidence  to  support  the  idea  of  pelvic  new-growth. 

In  every  case  characterized  by  sciatic  pain  we  should  remember 
that  diabetes  is  one  of  the  commonest  causes  for  such  pain.  There  is 
no  statement  about  the  urine  in  the  above  record  of  this  case,  and  evi- 
dence should  certainly  be  sought  in  that  direction. 

Largely  through  the  influence  of  Dr.  J.  E.  Goldthwait  the  medical 
profession  has  now  learnt  to  search  for  osteoarthritis  of  the  lumbar  spine 
or  for  some  lesion  of  the  sacro-iliac  joint  in  all  cases  of  sciatic  pain.  The 
nature  of  the  connection  between  the  pain  and  the  bone  lesions  has  not, 
I  think,  been  fully  explained  as  yet.  Most  of  the  important  evidence  of 
such  a  connection  consists  in  the  results  of  a  therapeutic  test — fixation 
of  the  spinal  and  sacro-iliac  joints  by  strapping,  belt,  or  plaster-of-Paris — ■ 
and  on  the  relief  of  symptoms  following  such  fixation.  This  is  of  great 
practical  importance,  but  does  not  answer  all  the  questions  regarding  the 
mode  of  production  of  sciaticas  thus  relieved.  In  the  present  case  we 
find  no  evidence  of  spinal  or  sacro-iliac  disease. 

The  term  "sciatic  rheumatism"  is  now  happily  falling  into  disuse, 
and  with  it,  I  believe,  will  soon  go  out  of  existence  the  hoary  and  over- 
worked theory  that  cold  produces  such  troubles.  Doubtless  it  was  their 
connection  with  joint  lesions  such  as  those  just  referred  to  that  first 
suggested  the  term  "rheumatic,"  with  the  theory  of  cold  as  the  cause. 
In  \iew  of  the  negative  result  of  all  the  examinations  directed  toward 
finding  a  cause  for  the  pain  we  shall  be  obliged  to  leave  it  as  an  unex- 
plained symptom  ("primary,"  "idiopathic,"  or  "simple"  sciatica). 
Since  it  is  associated  with  herpetic  eruption,  and  since  we  know  that 
many  cases  of  herpes  are  due  to  infectious  disease,  it  is  fair  to  surmise 
that  the  neuritis  with  which  we  are  now  dealing  may  be  of  the  infectious 
type.  All  this,  of  course,  presupposes  that  the  results  of  urinalysis  and 
x-ray  examination  are  negative. 

Outcome. — X-ray  of  the  femur  showed  a  large  callus  with  a  project- 
ing spicule,  but  as  there  had  been  no  pain  for  two  years,  this  seemed  prob- 
ably not  responsible  for  the  pain.  Dr.  J.  J.  Putnam  considered  the  case 
neuritis  with  herpes  zoster.     Dr.  Goldthwait  agreed. 

On  the  twenty-fifth  the  patient  was  discharged  much  relieved. 

Diagnosis. — Neuritis  with  herpes  zoster. 


PAIN  IN   THE   LEGS   AND   FEET 


3(>3 


Case  186 

An  Italian  pressman  of  forty-five  entered  the  hospital  March  26,  1906. 
Three  weeks  ago  he  gave  up  work  on  account  of  pain  in  his  hands  and 
feet,  which  has  been  severe  ever  since,  and  has  recently  kept  him  awake. 
His  appetite  is  poor  and  he  has  vomited  several  times.  He  attributes 
his  pain  to  the  fact  that  he  gets  very  wet  with  perspiration  at  his  work  and 
then  rides  home  upon  a  car.  He  got  very  cold  in  this  way,  just  before 
the  present  illness. 

The  course  of  the  temperature  is  shown  in  the  accompanying  chart. 
There  was  soft  edema  of  the  backs  of  both  hands.     The  right  wrist 


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and  left  elbow-joint  were  swollen,  slightly  stiff,  and  tender.  There  was 
tenderness  on  moving  the  fingers,  and  convincing  e\idence  of  fluid  in  the 
left  knee-joint. 

Both  ankles  were  somewhat  red,  swollen,  and  tender.  There  was 
tenderness  on  pressure  iii  the  calves  of  the  legs  and  over  the  muscles  of 
the  forearm,  a  bright  red  macular  rash  over  his  back,  with  small,  shiny 
])apules  scattered  through  it,  and  in  the  arm-pits  numerous  small,  dis- 
crete, transparent  vesicles.  He  was  seen  by  Dr.  Goldthwait  on  the 
twelfth  of  April.  He  found  at  this  time  an  infectious  ]~)roccss.  chiefly 
in  the  cellular  tissue,  with  very  little  involvement  of  the  joints. 

The  temy)crature  fell  to  normal  about  the  twentyeightli  of  March, 
but  on  the  thirty-first  the  patient  was  delirious  and  chattered  a  grea^: 


364  DIFFERENTIAL  DIAGNOSIS 

deal  in  the  night.  After  omitting  the  salicylates,  which  had  been  given 
steadily  up  to  that  time,  the  delirium  cleared  up  within  twelve  hours. 
The  knee-jerks  were  present,  but  the  Achilles  reflex  absent.  The  eyes 
reacted  better  to  accommodation  than  to  light.  The  urine  averaged 
60  ounces  in  twenty-four  hours,  the  specific  gravity  varying  very  widely 
between  1009  and  1020.  Hyaline  and  granular  casts  were  numerous,  and 
there  was  always  pus  in  the  sediment.  The  blood  showed  12,800  leuko- 
cytes, 81  per  cent,  of  which  were  polynuclear. 

On  April  4th  the  sweUing  of  the  hands  still  continued.  No  obvious 
change  in  his  condition  accompanied  the  fever  of  April  loth  to  19th. 

Purulent  conjunctivitis  was  present  throughout  his  stay  in  the 
hospital.  The  smear  showed  no  gonococci;  a  variety  of  other  organisms 
were  present.     May  ist  he  was  discharged,  not  relie^•ed. 

Discussion. — Judging  from  the  condition  of  the  pupils  and  of  the 
ankle-jerks,  there  seems  reason  to  believe  that  this  patient  has  tabes, 
but  evidently  that  is  not  his  most  important  malady  at  the  present  time, 
so  that  our  interest  centers  in  the  question :  What  else  is  the  matter  with 
him?  We  have  obvious  evidence  that  an  infectious  process  has  invaded 
the  subcutaneous  tissues,  the  joints,  and  the  conjunctivae.  In  all  prob- 
ability the  pus  in  the  kidney  is  to  be  attributed  to  a  genito-urinary  in- 
fection due  to  the  same  organism  which  is  attacking  his  other  tissues. 

At  one  period  in  the  case  it  seemed  as  if  the  meninges,  also,  were  in- 
fected, but  the  immediate  cessation  of  meningeal  symptoms  when  the 
salicylates  were  stopped  makes  it  pretty  clear  that  we  were  dealing  with 
a  salicylate  delirium,  which  should  always  be  borne  in  mind  when  any 
delirium  occurs  during  the  administration  of  salicylate  in  large  doses. 
This  is  a  very  frequent  occurrence.  Indeed,  it  is  impossible  to  avoid  it 
if  we  are  in  the  habit  of  pushing  this  drug  rapidly  to  its  physiologic  limit, 
as  we  should  do  in  most  cases  of  acute  arthritis.  No  considerable  harm 
results,  as  the  delirium  always  ceases  promptly  when  the  drug  is  with- 
drawn. 

We  have  evidence,  then,  of  a  very  wide-spread  infection  of  the  body. 
Presumably  this  is  due  to  one  of  the  pus-forming  organisms,  since  we 
have  no  definite  evidence  of  tuberculosis,  glanders,  or  syphilis.  No 
further  certainty  can  be  arrived  at  without  blood  culture. 

Milder  cases  of  this  type  are  often  called  ''inflammatory  muscular 
rheumatism"  (see  above,  p.  333),  just  as  the  milder  septic  infections 
of  the  joints  pass  as  articular  "rheumatism."  But  in  both  cases  there 
is  no  reasonable  doubt  that  we  are  dealing  primarily  with  an  infection 
of  the  blood-stream,  following  which  the  micro-organisms  take  root  and 
multiply  here  or  there,  foflowing  laws  of  distribution  which  we  do  not 


PAIN   IN   THE    LEGS    AND    FEET  365 

understand.  Evidently  the  joints  present  especially  favorable  condi- 
tions for  the  growth  and  multiplication  of  micro-organisms.  But  we 
see  many  instances  where  an  infection  which  seems  to  start  in  and  to  be 
distributed  by  the  blood-stream  gets  its  only  recognizable  localization 
in  the  heart,  lung,  kidney,  or  beneath  the  skin.  I  am  inclined  to  think 
that  the  gall-bladder,  the  meninges,  the  peritoneal  cavity,  and  possibly 
also  the  appendix,  should  be  added  to  this  list.  I  shall  return  to  the  fur- 
ther discussion  of  the  types  of  pyogenic  infection  in  the  section  on 
Fevers. 

Diagnosis. — General  pyogenic  infection. 

Case  187 

A  clerk  of  forty-nine  entered  the  hospital  January  3,  1907.  He 
had  previously  been  in  the  hospital  in  1889,  with  a  diagnosis  of  acute 
rheumatism  and  mitral  endocarditis.  Since  that  time  he  has  had  many 
similar  attacks.  The  attacks  seem  to  be  brought  on  by  cold,  indiscre- 
tions in  diet,  and  alcoholic  drink.  He  had  syphihs  in  1884,  and  later 
on  had  trouble  in  controlling  the  movements  of  the  bowels,  following  an 
operation  for  piles  and  fever. 

At  times  he  has  been  a  heavy  drinker.  Ten  days  ago  he  "got  cold" 
and  passed  bloody  urine.  Since  then  he  has  had  several  acute  attacks 
of  diarrhea. 

On  examination  his  pupils  are  slightly  irregular,  but  are  equal  and 
react  normally.  Marked  pronation  of  both  feet,  with  flattening  of  the 
arches,  is  noted.  The  second  joint  of  the  right  big  toe  is  immovable, 
thickened,  not  red  or  tender.  There  is  some  enlargement  of  the  joints 
of  the  fingers  and  toes.  A^-ray  shows  thin,  eroded  areas  on  the  fingers 
and  toes,  also  some  bony  outgrowth.     The  urine  shows  nothing  of  note. 

Discussion. — What  type  of  arthritis  are  we  dealing  with  here? 
The  association  of  the  previous  attack,  in  1889,  with  a  mitral  endo- 
carditis gives  us  some  ground  for  calling  it  a  rheumatic  arthritis,  although 
we  cannot  be  quite  sure  of  the  endocarditis,  since  there  are  no  signs  of  it 
at  present.  It  is  impossible  categorically  to  deny  that  a  mitral  endocardi- 
tis can  heal,  leaxing  no  sign  of  its  presence,  but  we  have  no  good  reason 
for  believing  so  at  the  j)resent  time.  Patients  with  true  rheumatism 
often  attribute  their  attacks  to  cold,  but  rarely  to  alcoholism  or  indis- 
cretions of  diet.  This  feature  of  the  history,  as  well  as  some  others 
presently  to  be  mentioned,  does  not  fit  the  ordinary  j)icturc  of  rlicumalic 
arthritis. 

Sy])hilitic  disease  of  the  joints  is  not  at  the  yiresent  time  a  very 
shary)ly  defmcd  clinical  entity,  but  tlie  cases  on   record  ha\e  not  Ijeen 


366  DIFFERENTIAL  DIAGNOSIS 

characterized  by  such  a  tendency  to  recurrence  and  speedy  recovery  as 
have  occurred  in  this  patient. 

Since  the  arches  of  the  patient's  feet  are  markedly  flattened,  we  must 
consider  whether  this  deformity  is  a  cause  or  result  of  his  symptoms. 
The  periodic  and  paroxysmal  character  of  the  patient's  sufferings  is  not 
at  all  characteristic  of  mechanical  weakening  of  the  arch.  Ordinary 
flat-foot  is  apt  to  cause  pain  until  it  is  relieved  by  treatment.  It  does  not 
appear  and  disappear  so  suddenly.  Against  flat-foot  also  is  the  presence 
of  eroded  areas  and  bony  outgrowths,  as  shown  in  the  .T-ray  plate. 

But  although  flat-foot  is  very  unlikely  as  a  cause  of  this  patient's 
troubles,  it  may  well  be  viewed  as  a  result  of  them,  since  almost  any  form 
of  arthritis  affecting  the  joints  of  the  foot  may  be  followed  by  flat-foot 
which  remains  as  a  cause  of  weakness  and  pain  after  the  inflammatory 
trouble  has  passed.  Thus  it  comes  about  that  many  cases  of  true  ar- 
thritis of  rheumatic  or  other  origin  are  best  treated,  when  they  reach  the 
doctor,  by  flat-foot  plates  and  exercises  designed  to  strengthen  the  ad- 
ductors of  the  foot.  The  inflammation  has  passed,  and  its  sequel  is 
mechanical  weakening,  not  an  infectious  process. 

The  A--ray  evidence,  the  thickening  and  stiffening  of  the  right  big  toe- 
joint,  and  the  apparent  relation  of  the  symptoms  to  indiscretions  in  diet 
suggest  gout.  Nothing  is  said  in  the  history  of  acute  night-attacks  of 
pain  in  the  great  toe,  nor  of  the  presence  or  absence  of  tophi.  But 
further  inquiry  showed  that  both  these  gouty  symptoms  were  present. 
Still  unexplained  is  the  relation  between  the  gouty  diathesis  and  the  bony 
outgrowths  seen  in  this  and  other  cases  of  gout,  as  well  as  in  the  hyper- 
trophic form  of  arthritis. 

Outcome. — On  the  fourth  of  February  the  patient  was  discharged 
quite  free  from  symptoms.  Tophi  were  still  present  in  his  ears,  and 
crystals  of  sodium  biurate  were  obtained  both  in  this  attack  and  four 
years  previously. 

Diagnosis. — Gout. 

Case  188 

A  housewife  of  twenty-nine  entered  the  hospital  January  14,  1908. 
She  was  delivered  of  her  first  child  on  December  2d,  but  previous  to  that 
delivery  she  had  much  pain,  owing,  as  she  supposed,  to  a  partially  re- 
tained placenta.  She  was  douched  and  cureted  twice  a  day  until  she 
decided  to  get  a  new  doctor.  The  second  physician  omitted  the  cureting. 
She  has  since  been  better. 

Two  days  after  delivery  both  legs  became  swollen,  and  were  still  so 
when  she  was  seen  January  14th.     On  entering  the  hospital  she  com- 


PAIN  IN  THE  LEGS  AND  FEET 


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plained  bitterly  of  pain  in  the  left  buttock.  Physical  examination 
showed  nothing  but  moderate  jaundice  and  a  bed-sore  over  the  left  sacro- 
iliac joint.  The  white  count  was  15,800;  two  days  later,  38,200.  On 
the  second  day  after  entrance  she  began  to  be  delirious,  and  this  con- 
tinued twenty-four  hours,  after  which  she  was  more  rational,  but  had 
occasional  hallucinations  at  night.  There  was  marked  dulness  through- 
out the  lower  abdomen.  The  uterus  was  soft,  flabby, 
and  somewhat  tender,  but  there  was  no  vaginal  dis- 
charge. 

By  the  sixteenth  the  edema  had  practically  dis- 
appeared from  the  right  leg,  and  was  less  in  the  left. 
A  blood  culture  was  taken,  which  showed  no  growth. 
Nevertheless,  antistreptococcus  serum  was  injected. 
The  urine  as  drawn  by  catheter  was  bright  green,  but 
showed  no  other  striking  abnormalities.  There  was 
some  tenderness  in  the  left  groin,  but  no  other  evidence 
of  thrombosis.  By  the  eighteenth  this  tenderness  had 
increased  and  there  was  considerable  fulness  in  the 
same  region. 

Discussion. — Fever  occurring  after  childbirth  and 
accompanied  by  jaundice,  by  marked  leukocytosis,  and 
by  pain  in  the  left  buttock  and  groin,  points  to  the  exis- 
tence of  some  deep-seated  septic  process  originating  in 
parturition.  Though  there  is  edema  in  both  legs,  we 
find  no  good  evidence  of  peripheral  thrombosis.  Pelvic 
thrombosis  possibly,  or  some  other  cause  for  pehic  obstruction  to  the 
circulation,  is  our  natural  conjecture,  since  all  the  other  symptoms 
appear  to  originate  in  the  pelvis.^ 

The  green  color  of  the  urine  is  presumably  due  to  biliverdin,  a  result 
— like  the  yellowing  of  the  conjunctiva — of  hemolysis.  Nothing  more 
definite  can  be  said  as  to  diagnosis.  Pehic  sepsis  we  doubtless  have; 
its  form,  extent,  and  origin  can  only  be  revealed  by  surgery  or  by  the  lapse 
of  time. 

Outcome. — Incision  allowed  the  escape  of  25  ounces  of  ])us,  tlie 
source  of  which  was  extraperitoneal  and  a])parently  extended  back  {o 
the  region  of  the  left  sacro-iliac  joint.  A  culture  showed  streptococcus. 
The  ])atient  died  a  week  later. 


Fig.  63. — Chart 
of  case  188. 


'  Any  one  %vho  has  scon  postmorlem  the  condition  of  the  uterine  and  the  iHriutcrinr 
tissues  in  the  days  soon  after  a  normal  lat>or  tannol  l)ul  wonder  how  any  woman  esiapes 
sci^sis  and  eml^oiic  infarctions  of  the  lung. 


368 


DIFFERENTIAL  DIAGNOSIS 


Autopsy  showed  several  fractures  of  the  pelvic  bones,  deep  burrow- 
ing pus  without  obvious  point  of  origin,  and  streptococcus  septicemia. 
The  course  of  the  temperature  is  seen  in  the  accompanying  chart. 
Diagnosis. — Fractured  pelvis  and  sepsis. 

Case  189 

A  medical  student  of  thirty-three  entered  the  hospital  March  2,  1907. 
On  February  21st  his  left  great  toe-Joint  swelled  up,  but  the  swelling 
was  gone  the  next  day.  He  then  began  to  have  pain  and  stiffness  in 
the  left  hip.  This  has  gradually  increased  ever  since.  Yesterday 
it  took  him  twenty  minutes  to  walk  three  blocks. 
No  other  joint  has  been  affected.  Any  hip  motion 
causes  pain  down  the  back  of  the  leg.  The  great- 
est tenderness  is  over  the  tuberosity  of  the 
ischium. 

At  the  onset  of  his  symptoms,  hives  appeared 
at  night  all  over  his  body,  some  of  the  lesions 
being  as  large  as  half  a  dollar.  They  always  dis- 
appeared in  the  day-time.  For  the  past  two 
days  he  has  not  had  them. 

Physical  examination  was  negative,  except  that 
all  motions  involving  the  hip-joint  caused  intense 
pain  extending  from  the  tuberosity  of  the  ischium 
down  the  back  of  the  leg. 

Rectal   examination  showed   marked  tender- 
ness on  the  right,  but   no  mass   or  fluctuation. 
The  case  was  considered  an  ischiorectal  abscess  by 
the  surgeons.     To  an    orthopedic   consultant    it 
appeared  to  be  an  infectious  arthritis  of  the  hip. 
The  white  count  at  entrance  was  27,400,  with  89  per  cent,  of  poly- 
nuclear  cells;   on  the  fifth  there  were  15,000;   on  the  twelfth,  9000. 
The  course  of  the  temperature  is  shown  in  the  accompanying  chart. 
By  the  tenth  of  March  the  pain  and  tenderness  were  much  less  and 
the  motions  of  the  thigh  freer.     By  the  thirteenth  he  was  almost  free 
from  symptoms  and  was  able  to  walk  about.     X-ray  was  negative.     Hot 
fomentations  and  sodium  salicylate  helped  him  very  much  in  the  early 
days  of  his  illness. 

He  was  discharged  on  April  9th  well. 

Discussion. — Pain  and  tenderness  in  the  hip  following  a  similar 
pain  in  the  toe  a  week  earlier  are  the  presenting  SATnptoms  here.  The 
hip  pain  has  sciatic  radiations,  and  is  accompanied  by  fever  and  leuko- 


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PAIN   IN   THE   LEGS    AND    FEET 


369 


cytosis.  No  source  of  infection  is  obvious.  There  has  been  no  injury 
to  account  for  the  symptoms. 

Our  first  business  is  to  examine  the  hip,  sacro-iHac  joint  and  spine. 
As  a  result  of  this  search  it  seems  that  only  the  hip-joint  is  affected, 
the  sciatic  pain  being  doubtless  secondary  to  this.  What,  then,  is 
the  infection  of  the  hip?  Tuberculosis,  the  commonest  of  hip  infections, 
has  rarely  so  acute  an  onset,  and  usually  occurs  in  younger  persons. 
The  high  white  count,  the  hives,  and  the  acute  brief  p>Texia  seem  more 
like  some  pyogenic  infection.  We  have  no  positive  evidence  of  gonorrhea 
or  of  any  other  infection  from  without. 

The  marked  tenderness  over  the  tuberosity  of  the  ischium  and  on 
rectal  examination  suggested  a  deep  ischiorectal  abscess,  especially  as 
the  leukocyte  count  was  so  high.  There  is  no  way  by  which  this  diag- 
nosis can  be  excluded,  though  it  is  rare  to  see  such  an  abscess  clear  up 
without  breaking  or  being  evacuated  externally.  It  is  a  well-known 
fact  that  some  cases  of  acute  arthritis  at  the  hip  produce  pain  in  the 
situations  complained  of  by  this  patient.  In  ^•iew  of  these  facts  and 
of  the  favorable  course  of  the  disease  without  external  manifestations 
of  abscess  it  seems  most  probable  that  the  case  was  one  of  acute 
arthritis  of  unknown  origin,  such  as  usually  receives  the  name  of 
"rheumatism." 

Diagnosis. — Acute  infection  of  the  hip. 

Case  190 

A  widow  of  forty-five,  with  a  negati\'e  family  history,  passed  the 
menopause  two  years  ago.  She  is  a  heavy  drinker.  Has  been  strong 
and  well,  but  in  the  past  two  years  has  lost  36  pounds.  She  now  weighs 
90  ])ounds. 

She  has  had  a  cough  since  last  fall,  with  a  grayish  sputa.  Has  been 
unable  to  work  for  a  year.  In  bed  most  of  the  last  five  weeks,  because 
of  [)ain  in  both  legs  and  hips.  Bowels  move  five  or  six  times  a  day  for 
the  past  six  months.     She  entered  the  hospital  August  15,  1Q04. 

Examhiation. — Left  pupil  larger  than  the  right,  and  reacts  to  light 
i)ut  not  to  accommodation.  Ptosis  of  right  eyelid.  At  left  base  behind 
and  in  the  left  axilla  the  breathing,  vocal  and  tactile  fremitus  are  dimin- 
ished, with  slight  dulness  and  many  fine,  crackling  rales.  Heart  negati\e. 
Consideral)le  tenderness  in  the  whole  l)elly.  Dulness  in  the  right 
hy[)ochondrium  and  tlank,  shifting  slightly  on  change  of  ])osition. 

Mass  felt  bimanually  in  this  region.  It  is  movable  antero]>(wieriorly 
and  with  respiration,  and  is  apparently  continuous  w  ith  the  li\er.  Na\el 
Hushed.     Lower  abdominal  veins  i)rominent.     Slight  edema  oi  tiie  l)elly- 


37° 


DIFFERENTIAL  DIAGNOSIS 


wall  and  of  feet.     Liver  dulness  reaches  from  the  fifth  space  to  four 
inches  below  the  ribs.     (See  Fig.  66.) 

Temperature,  ioi°  to  103°  F.  (see  Fig.  65).  The  white  cells  were 
5300.    Urine  negative. 

On  the  third  day  after  entrance  fluid  was  found  in  the  belly.  The 
Widal  reaction  was  negative.  On  the  sixth  day  she  had  three  hemor- 
rhages— ^  pint  each — from  the  bowel. 

Discussion. — The  past  history  is  of  special  importance  in  the 
interpretation  of  these  symptoms.  It  is  to  be  noted  that  a  woman  not 
previously  subject  to  cough  has  now  coughed  steadily  for  nearly  a  yeai, 
and  lost  continually  in  weight,  though  she  is  at  the  menopause.  As- 
sociated with  her  cough  the  chief  symptoms  have  been 
diarrhea  and  leg  pain. 

Summing  up  the  physical  examination,  we  may  say 
that  there  are  indications  of  very  wide-spread  lesions; 
the  ptosis  and  pupillary  changes  indicate  something 
wrong  at  the  base  of  the  brain.  The  lung  signs  must 
be  interpreted  (in  the  absence  of  cardiac  or  renal  ab- 
normalities and  in  the  presence  of  fever)  as  pleurisy 
with  effusion  or  thickening.  Finally,  below  the  dia- 
phragm, there  are  evidences  of  pressure  exerted  ap- 
parently upon  the  vena  cava  and  its  radicles  (as  well 
as  upon  the  spinal  nerve-roots),  by  the  mass  figured  in 
the  diagram.  The  liver  also  seems  to  be  much  enlarged. 
Cancer,  syphilis,  or  tuberculosis  are  the  three  diseases 
most  capable  of  producing  symptoms  distributed  through 
the  body  as  widely  as  those  in  this  case.  Syphilis  would 
account  for  the  ptosis  and  pupillary  changes.  If  we  inter- 
preted the  mass  below  the  diaphragm  as  a  syphilitic 
liver,  the  edema,  ascites  and  fever  would  be  explicable 
under  the  same  hypothesis.  The  pleurisy  and  leg  pains  would  remain 
unaccounted  for,  likewise  the  prolonged  cough.  The  diarrhea  might 
be  due  to  amyloid  disease  of  the  intestine  as  a  result  of  the  syphilis. 

Malignant  disease  of  the  liver  is  sometimes  associated  with  fever, 
and  would  explain  the  abdominal  symptoms  very  well,  but  would  not 
help  us  to  account  for  the  ocular  signs,  the  chronic  cough,  the  pleurisy, 
or  the  diarrhea.  In  the  great  majority  of  cases  hepatic  neoplasm  is 
preceded  by  marked  and  long-continued  gastric  suffering,  due  to  a 
preceding  neoplasm  of  the  stomach.  We  have  no  such  suffering  here. 
Tuberculosis  involving  the  base  of  the  brain,  the  pleura,  the  intes- 
tine, and  peritoneum  would  account  for  all  the  facts  in  this  case.     Under 


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of  case  190. 


t'lK-  66. —  C'or.dition  of  the  alxloiiuMi  in  Case   190;    ht'diiddrn  hy  jaiii  in  Uoth  \c^. 


PAIN  IN  THE  LEGS  AND  FEET  371 

this  hypothesis  the  intestinal  hemorrhages  result  from  ulcerations  of 
the  gut,  while  the  mass  above  the  umbilicus  represents  a  conglomera- 
tion of  caseous  glands  and  adherent  intestinal  coils.  Enlargement  of  the 
liver  might  be  due  to  fatty  or  amyloid  metamorphosis.  By  strict  reason- 
ing this  diagnosis  seems  the  most  probable. 

Outcome. — The  patient  died  August  i8th.  Autopsy  showed  ex- 
tensive tuberculosis  of  the  mesenteric  and  retroperitoneal  lymphatic 
glands,  also  of  the  large  and  small  intestine,  with  ulcerations  evidently 
the  source  of  hemorrhage.  There  were  long-standing  tuberculosis  of 
both  lungs  and  a  general  miliary  infection. 

Diagnosis. — Tabes  mesenterica.    General  tuberculosis. 

Case  191 

A  housewife  of  thirty-seven  entered  the  hospital  October  i8,  1907. 
Her  family  history,  past  history,  and  habits  are  good.  For  the  past 
four  and  one-half  years  she  has  had  frequent  attacks  of  severe  pain 
in  the  back  of  the  left  thigh,  running  down  the  leg,  preceded  often  bv 
a  mild  chill,  and  rclic\ed  after  five  or  six  hours  of  sweating.  She  is 
also  troubled  by  nervousness  and  apprehension,  and  has  worried  a 
good  deal  since  last  winter  al)out  a  prunc-stone  that  slie  swallowed. 
She  wonders  where  it  is  now.  Her  sleep  and  api)etite  are  i)Oor,  and  she 
has  frequent  attacks  of  headache  and  nausea,  with  some  flatulence 
after  eating  and  considcral)le  consti])ation. 

Ph}sical  examination  showed  great  restlessness;  no  swelling,  tender- 
ness, or  limitation  of  motion  in  any  part  of  either  leg.  The  arches  of  Ijoth 
feet  were  found  to  be  much  flattened.  The  rest  of  the  examination, 
including  the  ])clvis,  the  l^lood,  and  the  urine,  was  negative. 

Discussion. — ]n  view  of  the  negative  results  of  a  searching  physical 
examination  and  of  general  obscr\'ation  under  hospital  conditions, 
we  seem  dri\'cn  to  the  diagnosis  of  a  ])sychoneiirosis  with  llat-foot  and 
sciatica.  Only  l)y  the  continued  study  and  ])r()l()nged  obscrNation  of 
such  cases  can  we  realize  the  harm  done  by  semiconscious  fears  based 
on  such  an  incident  as  the  swallowing  of  a  ])rune-stone.  l^sj)ecially  in 
y)crsons  who  have  no  knowledge  of  anatoniv  ;in(l  physiolog}',  the  imagina- 
tion runs  riot  in  speculation  o\-er  the  ])ossil)le  ]»aths  which  sucli  a  stone 
might  travel.  \'ery  great  l^enefit  follows  in  such  rases  it  the  ])atient 
can  be  assured,  as  a  result  of  exhausti\"e  ]thysical  examination,  that  no 
organic  lesion  exists. 

An  element  in  this  benefit  is  the  result  of  the  ]>atii'nt"s  oi>portr,nity 
to  bring  to  full  consciousness,  as  the  resr.lt  of  the  ph\>iiian's  (|iirslions, 
the   \'a<nie   and    unformed   dreads   from    which    he   has   been   s'.illerinL:. 


372  DIFFERENTIAL   DIAGNOSIS 

As  soon  as  they  are  forced  to  take  shape,  many  of  these  apprehensions 
are  alleviated,  as  the  child's  terror  is  gone  when  it  has  recounted  its 
nightmare  to  its  mother.  To  this  familiar  psychologic  rule  the  name 
of  the  "cathartic  method"  has  been  given  by  Breuer  and  Freud.  The 
essential  point  is  that  ideas  or  emotions  which  do  the  most  harm  to 
the  body  are  often  the  most  deeply  hidden  beneath  the  superficial 
layers  of  consciousness.  The  patient  himself  may  be  altogether  unaware 
of  their  existence  or  may  manifest  his  vague  cognizance  of  them  only 
by  a  systematic  refusal  to  face  them  squarely,  either  in  his  own  mind 
or  in  conversation  with  his  physician.  It  is  for  this  reason  that  the 
physician  must  sometimes  employ  what  Freud  calls  "psycho-analysis" 
— the  effort  to  find,  by  a  persistent  process  of  drawing  the  patient  out, 
submerged  ideas  which  resist  more  or  less  unconsciously  the  attempts 
to  drag  them  to  the  surface.  The  process  is  risky,  but  occasionally 
valuable. 

Outcome. — After  a  week's  rest  and  several  long  talks  with  her 
physician,  counterirritation  to  the  thigh,  laxative  medicines  and  proper 
shoes,  she  was  discharged  much  relieved. 

Diagnosis. — Flat-foot;  psychoneurosis. 

Case  192 

A  cook  of  thirty-six  entered  the  hospital  March  14,  1907.  At 
irregular  intervals  for  five  or  six  years  she  has  had  sharp  pains  in  her 
arms  and  fingers,  sometimes  lasting  as  long  as  a  week,  usually  worse 
in  summer.  During  the  last  five  years  she  has  grown  very  stout,  her 
average  weight  being  175  pounds.  Otherwise  her  past  history  is  good, 
likewise  her  family  history  and  her  habits.  She  was  perfectly  well 
until  eight  days  ago,  when  she  began  to  have  pain  in  her  heels,  later 
passing  around  to  the  front  of  the  foot,  but  never  to  the  toes  nor  to  the 
ankles.  The  pain  kept  her  awake  at  night,  and  the  foot  has  been 
swollen,  red,  and  tender  to  touch.  She  has  been  in  bed  for  the  last  three 
days,  and  seems  to  have  been  getting  worse. 

The  patient  is  5  feet  4  inches  tall,  very  obese;  chest  and  abdomen 
are  negative;  reflexes  normal;  no  tenderness  over  the  joints  of  the  feet. 
After  a  few  days  in  bed  the  patient's  pain  was  gone.  There  w^as  no 
fever,  and  physical  examination,  including  the  blood  and  urine,  was 
otherwise  negati\'e. 

Discussion. — This  seems  to  be  a  case  of  obesity  with  pain  in  the 
feet;  the  nature  of  this  pain  it  is  our  problem  to  discover.  Is  it  of  me- 
chanical or  infectious  origin?  The  redness,  tenderness  and  swelling  look 
like  infection,  but  there  is  no  fever  or  leukocytosis,  no  involvement  of 


PAIN  IN  THE  LEGS  AND  FEET  373 

any  other  joints,  and  experience  has  shown  that  even  redness  and 
swelling  may  result  from  the  mechanical  causes  leading  to  the  acuter 
forms  of  flat-foot.  We  are  influenced  especially  toward  the  latter 
hypothesis  when  we  find  that  there  was  no  tenderness  in  the  foot-joints, 
but  only  in  the  soft  parts.  The  fact  that  she  gets  better  as  soon  as  she 
is  off  her  fe&t  is  evidence  pointing  in  the  same  direction. 

Very  similar  symptoms  are  often  seen  in  gout,  but  I  see  no  way  of 
coming  to  any  closer  terms  with  this  possibility,  since  we  have  no  tophi, 
no  night  attacks  of  pain  in  the  great  toe,  and  no  knowledge  of  a  heredity 
or  habit  of  life  predisposing  to  gout. 

Outcome. — Padding  the  feet  gave  temporary  relief.  Much  more 
permanent  benefit  followed  the  adjustment  of  flat-foot  plates. 

This  case  well  illustrates  one  of  the  indirect  evils  resulting  from 
obesity.     There  are  many  cases  of  obesity  which  do  not  call  for  treat- 
ment by  reason  of  the  inconvenience  or  unsightliness  of  the  fat,  but 
which  entail,  nevertheless,  a  genuine  risk  to  the  patient.     At  any  time 
;\  the  heart  may  be  slightly  weakened  or  the  feet  slightly  strained  by  some 
I'jtemporary  cause.     In  the  obese  the  results  of  these  otherwise  trivial 
'-injuries  may  be  a  serious  and  obstinate  illness.     During  this  illness  it 
\  is  rarely  wise  to  attack  the  obesity.     Later,  when  the  acute  suffering  is 
past,  the  patient  may  be  unwilling  to  submit  to  the  privations  entailed 
I  by  the  attempt  to  reduce  his  fat.     Thus  many  patients  go  on  from  bad 
to  worse.     Their  good  resolutions  cannot  be  summoned  at  the  right  time. 
Diagnosis. — Acute  foot-strain. 

Case  193 

A  bartender  of  twenty-nine,  with  negative  family  history  and  past 
history,  entered  the  hospital  January  29,  1908;  he  has  been  in  the 
habit  of  taking  25  glasses  of  beer  a  day,  and  one  whisky  every  morning. 
For  the  past  six  months  he  has  been  growing  short  of  breath,  and  lately 
has  needed  two  or  three  pillows  at  night.  He  has  no  digesti\-c  symptoms, 
but  rarely  eats  any  breakfast.  Five  weeks  ago  he  began  to  notice  a 
swelling  of  his  legs  below  the  knee,  accompanied  by  soreness  and  stiffness. 
The  swelling  disappeared  after  five  days,  but  he  continued  to  feel  poorly 
and  three  weeks  ago  gave  up  work.  Throughout  his  illness  he  has  had 
slight  cough  and  white,  frothy  sputum.  Eight  days  ago  he  began  to  have 
considerable  pain  in  both  ankles  and  the  left  knee,  without  any  s\NcninL:, 
redness,  or  fe\er. 

His  pains  have  never  been  of  a  darting  character. 

His  eve-sight  is  good.  He  has  had  no  licadachc.  For  the  ])ast 
ei<;;ht  davs  he  has  been  in  bed. 


374 


DIFFERENTIAL   DIAGNOSIS 


As  seen  by  the  accompanying  chart,  the  patient  had  a  slight  fever 
the  first  five  days  of  his  stay  in  the  hospital.  This  was  accompanied 
by  a  leukocytosis,  which  on  January  29th  reached  17,800;  January  30th, 
18,800.  The  urine  was  sufficient  in  amount,  averaging  1017  in  specific 
gravity,  with  a  very  slight  trace  of  albumin,  but  no  casts.  His  pupils 
reacted  well  to  light  and  distance.  The  aortic  second  sound  was  mark- 
edly accentuated.     The  heart  was  otherwise  normal,  also  the  lungs. 

The  pulse  tension  was  apparently  increased. 
The  edge  of  the  liver  was  felt  one  finger's 
breadth  below  the  edge  of  the  ribs,  like- 
wise the  spleen.  There  were  considerable 
tremor  of  the  fingers  and  obstinate  insomnia. 
Within  a  few  days  he  began  to  have  pain 
in  both  arms,  accompanied,  as  in  the  legs, 
by  tenderness  to  pressure,  although  the 
reflexes  were  everywhere  normal. 

Discussion. — Chronic    alcoholism,    six 
months'  dyspnea  and  cough,  and  five  weeks 
of  leg  pain  are  the  essential  data  of  the  his- 
tory.    Tabes  is  always  to  be  thought  of  in 
men  of  these  habits,  but  there  is  nothing  in 
the  physical  examination  to  verify  this  con- 
jecture.    Doubtless    the  great  majority  of 
such  cases  are  destined  to  be  labeled  "rheu- 
matism," chiefly  because  they  do  not  pre- 
sent a  clear  picture  of  any  more  definite 
malady.     But  there  seems  no  good  reason  to  fall  back  upon  this  ancient 
darkener  of  counsel  when  we  have  no  fever  and  no  special  tenderness 
over  the  joints. 

Alcoholic  neuritis  is  the  natural  explanation  of  diffuse  leg  pains 
occurring  in  an  alcoholic  without  fever  or  evidence  of  local  inflamma- 
tion. But  in  this  as  in  most  cases  caUed  alcohoHc  neuritis,  we  cannot 
answer  the  question,  Why  is  this  man  stricken  at  this  particular  time; 
Why  does  the  result  appear  so  tardily  when  the  cause  has  been  busy 
throughout  so  many  years?  Doubtless  there  is  some  other  determining 
factor  of  which  we  are,  as  yet,  quite  ignorant. 

Outcome. — The  patient  was  given  sodium  bromid,  20  grains,  after 
breakfast  and  dinner,  and  30  grains  at  night.  Twice  he  needed  |  grain 
morphin.  For  his  cough  he  was  given  a  prescription  containing  3 
grains  of  codein,  15  minims  of  spirits  of  chloroform,  3  ounces  of  syrup 
of  wild  cherry.      Of  this  mixture  a  dram  was  gi\en  every  two  hours 


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Fig.  67. — Chart  of  case  193. 


PAIN  IN  THE  LEGS  AND  FEET  375 

when  the  cough  was  troublesome.  On  the  first  of  February  he  was 
given  15  grains  of  sodium  saHcylate  four  times  a  day.  By  the  ninth 
of  February  he  was  free  from  symptoms,  but  had  sHght  toe-drop  and 
sHght  tenderness  in  the  calves. 

He  was  advised  to  avoid  alcohol,  and  went  home  on  the  tenth  of 
February. 

Diagnosis. — Alcoholic  neuritis. 

Case  194 

A  plasterer  of  thirty-seven  entered  the  hospital  June  12,  1907. 
He  had  his  first  attack  of  rheumatism  at  seventeen,  when  he  was  sick 
for  several  months.  He  has  since  then  had  five  or  six  other  attacks, 
and  since  his  last  attack,  which  lasted  a  month  (five  months  ago),  he 
has  had  a  weak  heart  and  more  or  less  pain  in  various  parts  of  his  body. 
He  has  had  urethral  discharge  off  and  on  since  he  was  seventeen,  until 
five  years  ago;  not  since  then.  He  takes  from  two  to  six  glasses  of  beer 
and  one  or  two  whiskies  a  day.  Two  weeks  ago  he  began  to  have  pain 
and  swelling  in  his  feet  and  knees,  and  got  transient  relief  from  a  Turkish 
bath.  He  has  also  had  considerable  severe  pain  in  the  region  of  his 
heart  and  right  lower  ribs  for  the  past  two  weeks.  He  has  had  Aery 
little  fever,  but  has  sweated  a  great  deal.  For  the  past  fortnight  he 
has  been  troubled  with  many  attacks  of  "  hives,"  which,  however,  have 
not  bothered  him  for  the  last  two  or  three  days.  Throughout  his  illness 
he  has  had  a  cough,  with  whitish,  frothy  sputa.  His  appetite  is  poor. 
His  bowels  mo\e  twice  a  day.  He  has  slept  fairly  well.  The  course 
of  the  temperature  is  seen  in  the  accompanying  chart. 

Examination.— The  heart's  apex  was  seen  and  felt  in  the  fourth 
space,  four  inches  from  the  midsternum  in  the  nipple-line.  There  was 
no  enlargement  to  the  right.  The  sounds  were  regular  and  of  good 
cjuality;  the  ])ulmonic  second  sound  accentuated.  A  blowing,  systolic 
murmur  was  heard  best  at  the  apex,  very  faintly  over  the  rest  of  the 
prccordia  and  in  the  axilla.     The  pulses  showed  nothing  remarkable. 

The  right  lung  was  dull  l)elow  the  third  ril)  in  front  and  below  the 
angle  of  the  scapula  ])ehind.  Over  this  area  distant  ])ronchial  l)reathin,<: 
with  increased  fremitus  was  detcctal.  Just  above  the  dull  area,  laint 
crackling  rales  were  heard.  The  abdomen  was  ncgati\e.  'J'hc  rJLilit 
knee  and  shoulder,  left  shoulder  and  elbow,  were  slightly  stiff  and  painhil 
on  motion. 

Xo  sjjutum  examined.  The  leukocyte  count  was  22,000  at  riitranre, 
16.000  on  the  first  of  July,  12,000  on  the  third  of  July,  and  rauLani  lower 
after  that  time.     The  urine  was  esscntiallv  normal. 


:^'j6  DIFFERENTIAL   DIAGNOSIS 

Discussion. — We  can  arrive  at  no  clear  conclusion,  nor  even  at  any 
helpful  clue,  from  reading  the  first  paragraph  of  this  record.  The 
patient  has  had  many  attacks  of  arthritis,  some  or  all  of  which  may 
have  been  due  to  gonorrhea,  but  it  is  not  probable  that  his  present 
joint  pains  are  gonorrheal  in  origin,  as  he  has  had  no  local  signs  of 
that  disease  for  five  years.  His  other  symptoms — cough,  sweating, 
chest  pain,  urticaria,  and  anorexia — are  very  indefinite.  Pleurisy  is 
perhaps  the  possibility  most  indicated. 

On  physical  examination  we  find  the  evidence  of  multiple  arthritis, 
of  solidified  lung  (right  lower  lobe),  and  possibly  of  mitral  regurgitation. 
All  of  these  might  be  due  to  a  single  infectious  agent,  such  as  the  pneu- 
mococcus  or  tubercle  bacillus.  So  far  as  I  know  there  is  no  good  evidence 
that  the  gonococcus  can  produce  pneumonia,  although  it  might  explain 
the  other  lesions  from  which  the  patient  is  suffering.  The  temperature 
chart  (Fig.  68)  is  by  no  means  characteristic  of  pneumococcus  infec- 
tion, nor,  indeed,  of  any  other  acute  infection.  It  is  more  suggestive 
of  tuberculosis. 

If  we  are  to  clear  up  the  diagnosis  any  further  our  chief  need  seems 
to  be  a  knowledge  of  the  sputa,  which  should  be  repeatedly  and  care- 
fully examined.  I  have  known  tuberculous  pneumonia  to  begin  with 
just  such  a  history  and  with  very  similar  symptoms,  including  even 
the  joint  pains.  On  the  other  hand,  many  of  the  irregular,  low-grade 
pneumonias,  associated  with  a  cardiac  lesion  and  with  some  organism 
other  than  the  pneumococcus,  present  a  picture  much  like  this. 

Outcome. — The  patient  was  treated  by  tight  chest  swathe;  15 
grains  sodium  salicylate  every  four  hours,  chloroform  liniment,  an 
occasional  dose  of  trional  or  morphin,  and  hot  applications  to  the  joints. 
On  the  seventh  of  July  his  only  complaint  was  of  weakness.  At  the 
right  base  there  was  still  dulness,  but  the  breathing  and  fremitus  were 
diminished.  These  signs  gradually  disappeared,  and  he  was  discharged 
well  on  the  seventh  of  August. 

Diagnosis. — Pneumococcus  arthritis,  endocarditis  (?),  and  pneu- 
monia. 

Case  195 

A  bartender  of  fifty  entered  the  hospital  March  24,  1908.  Four 
weeks  ago  he  had  an  attack  of  rheumatism  in  his  feet,  ankles,  and  in 
his  shin,  just  above  the  ankles.  The  ankles  were  swollen,  red  and 
tender.  He  took  5  grains  of  aspirin  every  four  hours  on  the  fourth 
day  of  his  trouble,  and  in  a  day  or  two  his  pain  had  gone,  but  ever  since 
then  he  has  been  feeling  mean  and  cannot  sleep.     He  still  has  difficulty 


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Fig.  68. — Chart  of  Case  194. 


PAIN  IN  THE  LEGS  AND  FEET  379 

in  walking,  but  can  hop  round  fairly  well.  His  appetite  and  bowels 
are  normal.  He  gets  up  six  or  eight  times  at  night  to  pass  water,  and 
thinks  he  passes  more  at  night  than  during  the  day.  (This  observation 
was  verified  during  his  stay  in  the  hospital.) 

There  were  various  rose-colored  macules  scattered  over  the  trunk. 
The  pupils  were  found  to  be  irregular,  but  reacted  normally. 

Along  the  margin  in  each  ear  there  were  some  white,  firm  nodules, 
the  size  of  a  pin's  head,  resembling  sebaceous  cysts,  but  sur])risingly 
hard.  The  radials  w^re  tortuous;  pulse  of  high  tension;  blood-pressure 
175;  aortic  second  sound  slightly  accentuated.  No  cardiac  enlargement 
could  be  demonstrated,  and  the  heart  showed  no  other  abnormality. 
The  breathing  was  slightly  harsh  in  the  left  back,  below  the  angle  of 
the  scapula;  otherwise  the  lungs  showed  nothing  almormal.  The 
abdomen  was  normal.  There  was  flattening  of  the  arches  of  both  feet, 
especially  the  left;  blood  and  urine  were  normal,  except  that  the  urine 
was  persistently  of  low  gra\'ity, — loii, — with  the  slightest  jiossible  trace 
of  albumin,  but  no  casts. 

Discussion. — Arthritis,  hypertension,  nocturia,  irregular  pupils 
and  flattened  arches  are  the  main  points  on  which  we  may  be  clear 
from  the  start  in  this  case.  There  seems  good  reason  to  belie\e  that 
the  patient's  kidneys  are  somewhat  atrophic,  although  no  cardiac 
enlargement  can  be  made  out  as  a  support  for  this  hy})othesis.  The 
remaining  question  is:  Docs  flat-foot  account  for  all  the  rest  of  his 
symptoms,  or  is  the  weakening  of  his  arches  secondary  to  some  form 
of  arthritis?  This  brings  us  to  the  more  careful  consideration  of  the 
nodules  on  the  patient's  ears,  for  any  case  of  doubtful  joint  lesion, 
es])ecially  in  the  feet,  calls  for  a  careful  scrutiny  of  the  aural  cartilages. 
If  the  nodules  on  the  ear  were  sebaceous  cysts,  they  \\ould  be  soft, 
nc\er  hard.  Such  multii)le,  firm  white  nodules  along  the  ear  margin 
may  rei)resent  the  sodium  biurate  deposits  of  gout.  They  may  also 
occur  when  the  ear  has  been  frozen.  The  crucial  test  is  to  ascertain 
whether  we  can  dig  out  of  one  of  these  nodules  a  chalky,  gritty  ])owdcr, 
showing  fine,  needle-like  crystals  under  the  microscope.  In  the  presciit 
case  we  o])tained  such  crystals  and  our  diagnosis  was  made. 

Outcome, — He  was  given  wine  of  colchicum  root,  20  minims  ewry 
four  hours;  veronal,  10  grains,  for  the  first  two  nights;  magnesium 
sul])hate,  \  ounce  e\ery  morning.  I5y  the  twenty-nintli  his  digi'stiw: 
disturbance  was  gf)ne  and  he  felt  nnich  belter.  Tlie  colchicuni  sccnied 
U)  ])r()(luce  diarrhea,  and  was  promptly  omitted.  Tliereaflcr  lie  \Nas 
gi\en  a  liberal  diet,  and  by  A])ril  2d  was  discharged,  rcliexed. 

Diagnosis,—  Ciout. 


380  DIFFERENTIAL  DIAGNOSIS 

Case  196 

A  widow  of  fifty-five  entered  the  hospital  December  10,  1907.  Her 
family  history  is  good.  Fifteen  years  ago  she  had  cataract  in  both 
eyes,  and  was  very  successfully  operated  on,  so  that  now  she  has  very 
fair  vision.  As  long  as  she  can  remember  she  has  passed  urine  five  or 
six  times  every  night.  She  passed  the  menopause  two  years  ago,  without 
event. 

A  year  ago  she  began  to  have  transitory  numbness  in  the  right  hip 
and  along  the  back  of  the  right  thigh.  Six  months  ago  she  began  to 
have  a  burning  pain  extending  from  the  right  knee  to  the  right  hip  when- 
ever she  remained  seated  for  any  length  of  time.  She  took  osteopathic 
treatment  during  the  summer,  and  was  assured  that  her  hip  had  been 
out  of  joint,  but  was  now  properly  set.  Nevertheless  she  did  not  improve. 
In  July  the  pain  was  sharp,  shooting,  and  often  kept  her  awake.  Since 
August  it  has  been  very  bad  until  the  first  of  December,  since  when  it 
has  been  rather  better.  When  the  pain  is  severe,  there  is  often  involun- 
tary twitching  of  the  foot  and  leg.  This  was  more  frequent  six  weeks 
ago  than  it  is  now. 

At  present  the  leg  feels  fairly  comfortable  during  the  night  and  in 
the  morning,  but  after  she  has  been  up  for  half  an  hour  or  so  it  begins 
to  feel  numb,  and  in  a  short  time  there  is  a  burning  and  shooting  pain 
which  comes  and  goes  through  it.  The  back  of  the  thigh  and  some- 
times the  lower  leg  are  markedly  tender  to  touch.  There  has  been  no 
pain  in  the  back,  no  eruption,  no  fever.  She  has  been  in  bed  or  on  a 
sofa  most  of  the  time  for  the  last  four  months,  and  has  lost  about  25 
pounds  in  weight. 

The  aortic  second  sound  is  louder  than  the  pulmonic,  and  is  preceded 
by  a  faint  murmur  transmitted  up  to  the  cla\icle  and  down  to  the  third 
space.  Another  murmur  is  heard  with  the  first  sound  at  the  apex, 
but  is  not  transmitted.  In  the  lumbar  and  dorsal  region  there  is  con- 
siderable curvature  of  the  spine  with  convexity  to  the  left.  The  ribs 
to  the  left  of  the  spine  are  prominent.  The  abdomen  and  all  the  deep 
reflexes  normal.  In  the  right  groin  there  are  glands  somewhat  larger 
than  the  average.  There  is  tenderness  along  the  right  sciatic  nerve 
and  in  the  right  calf.  The  patient  is  apparently  more  relieved  by 
^^  gr.  of  codein  taken  from  her  own  bottle,  of  which  she  is  very  fond, 
than  by  larger  doses  of  morphin  and  codein  given  her  in  the  hospital. 
There  seems  to  be  a  large  mental  element  in  her  suffering. 

Discussion. — In  seeking  the  origin  of  this  pain  it  is  natural  to 
think  first  of  the  spinal  curvature,  which  has  forced  the  ribs  apart  on  the 


Fig.  69. — Outline  of  the  mass  referred  to  on  p.  381. 


lig.  70. — Mass  ai)])arctitly  the  cause  of  sciatic  ]'air 


PAIN    IN   THE    LEGS   AND    FEET  38 1 

left  and  jammed  them  together  on  the  right.  But  it  is  hard,  to  see  how 
this  could  produce  suffering  confined  to  the  leg.  Some  of  the  intercostal 
nerves  would  probably  be  involved. 

We  next  consider  the  different  varieties  of  arthritis  invohing  the 
hip,  spine  or  sacro-iliac  joint.  Infectious  arthritis  would  hardly  last 
so  long.  Osteo-arthritis  would  probably  cause  some  pain  in  the  back, 
and  would  be  unlikely  to  be  worse  in  the  sitting  posture.  Further, 
the  pain  produced  by  it  is  hardly  ever  confined  to  the  leg.  A''-ray  ex- 
amination might  help  positively  to  exclude  this  disease.  Sacro-iliac 
disease  seems  more  probable.  Against  it,  howe\er,  is  the  gradual 
onset,  the  age  and  sex,  and  the  absence  of  any  tenderness,  pain  or 
palpable  abnormality  in  that  joint. 

Some  facts  stated  in  the  record  incline  us  to  believe  that  the  pain 
may  be  of  the  functional  or  neurotic  type.  But  before  one  settles  down 
upon  such  a  diagnosis  or  tries  to  content  himself  with  calling  the  trouble 
a  "  primary  sciatica  "  the  pelvis  should  be  thoroughly  investigated  for 
possible  sources  of  pressure.'  The  slight  enlargement  of  the  inguinal 
glands  makes  such  an  investigation  all  the  more  important. 

Outcome. — Vaginal  examination  showed  in  the  right  side  of  the  pehis 
a  firm  mass,  tender  on  pressure,  seemingly  attached  to  the  pehic  v.all 
(Fig.  69).  The  right  thigh  and  calf  were  found  to  be  V  inch  smaller 
than  the  left,  but  there  was  only  slight  weakness  of  the  leg;  no  paralysis. 

Later,  a  large  mass  was  found  in  the  region  of  the  right  buttock 
(see  Fig.  70).  A"-ray  showed  no  definite  abnormalities.  On  the 
second  of  January  one  of  the  glands  was  removed  from  the  groin,  and 
histological  examination  showed  it  to  be  malignant  disease. 

On  the  fourteenth  of  January  the  patient  was  discharged  some\\'hat 
relieved. 

Diagnosis. — Pehic  neoplasm. 

Case  197 

A  colored  scrub-woman  of  forty-nine,  whose  husband  had  ]:)reviously 
been  treated  at  the  hospital  for  syj)hilis,  but  whose  own  family  history, 
past  history,  and  habits  were  not  in  any  way  remarkable,  entered  UK- 
wards  December  26,  IQ07.  Since  February  she  has  been  gradually 
nmning  down,  l)ut  worked  until  four  days  ago.  During  these  mojuhs 
she  has  grown  very  weak  and  thin.  Her  meals  have  been  scanty  and 
irregular  for  some  time,  and  once  or  twice  a  week  she  has  xoiiiitiim 
spells,  apparently  without  relation  to  the  nature  of  her  food.  Siiuc 
last  winter  she  has  l)een  troubled  by  cold  sensations  in  the  ktt  Ivj.  and 
more  or  less  constant  aching  there.     For  the  last  two  or  three  months 


382 


DIFFERENTIAL   DIAGNOSIS 


The  edge  of  the  liver  was 


A/!E>  or 

A«STHtSiA 
^rmiD  wiTM  Pin) 


she  has  limped,  and  occasionally  she  has  been  short  of  breath  in  going 
upstairs. 

The  chest  showed  nothing  abnormal 
easily  felt.  The  left  knee-jerk  could  hardly  be  obtained,  although  the 
right  one  was  easily  brought  out.  The  left  Achilles  jerk  could  not  be 
obtained  at  all.  The  leg  was  quite  warm  to  touch,  although  the  patient 
complained  of  its  being  cold.  Both  legs  could  be  extended  more  than 
normal  upon  the  flexed  thigh,  without  pain.  There  was  no  tenderness 
along  the  course  of  the  sciatic  nerve,  but  slight  sensitiveness  on  firm 

pressure  over  the  left  calf.  An  area 
of  anesthesia  was  found,  as  shown 
in  the  accompanying  diagram.  Lift- 
ing the  left  leg  with  the  knee  stiff 
caused  pain  throughout  the  leg. 
Lifting  the  right  leg  produced  no 
discomfort. 

Discussion. — Evidently  we  are 
dealing  here  with  a  neuritis  involving 
the  sciatic  and  probably  other  nerve- 
trunks.  But  as  usual  in  such  cases 
the  diagnostician's  chief  task  is  to 
search  for  a  cause  for  the  neuritis. 
It  seems  probable  that  the  patient 
has  had  syphilis,  but  syphilitic 
lesions  so  localized  as  to  produce 
a  neuritis  confined  to  one  extremity 
^^^-  do  not  occur,  so  far  as  I  am  aware. 

Tuberculosis  is  so  common  in  the  negro  race  that  it  is  natural  to 
suspect  it  whenever  a  negro  is  seriously  sick.  But  there  seems  to  be 
no  limitation  of  motion  in  any  joint  and  no  other  evidence  of  muscular 
spasm,  burrowing  abscess,  telescoping  of  joints,  fever,  or  any  other 
result  of  tuberculosis.  The  area  of  anesthesia  and  the  long,  steady 
duration  of  the  pain  make  it  more  than  ordinarily  probable  that  we  are 
dealing  with  a  pressure  neuritis,  the  position  of  which  must  be  investi- 
gated by  radioscopy  and  by  pelvic  examination. 

Outcome. — Inspection  of  the  cer^•ix  uteri  shows  the  cervical  canal 
to  be  open,  f  inch  in  diameter  and  lined  with  small,  i)rojccting  nodules. 
The  patient  has  a  slight  uterine  flow  each  day,  but  no  foulness.  The 
uterus  extends  half-way  up  to  the  na^■el.  Lifting  the  straightened 
left  leg  causes  moderate  pain;   lifting  the  right,  no  ])ain. 

January  7th  a  nodule  was  removed  from  the  uterus,  and  shown  by 


Fig.  71. — Shows  anesthetic  areas  re- 
ferred to  on  p.  382.  Complaints:  Ach- 
ing  and   paresthesia   (coldnessj   in  left 


PAIN  IN  THE  LEGS  AND  FEET 


383 


microscopic  examination  to  be  cancer.     Presumably  there  were  metas- 
tases in  the  broad  ligament,  causing  pressure  upon  the  pelvic  nerves. 
Diagnosis. — Carcinoma  uteri. 

Case  198 

A  colored  housewife  of  thirty-two  entered  the  hospital  June  7,  igo8. 
Her  family  history  and  past  history  were  excellent,  her  habits  good. 
Since  last  fall  she  has  had  some  pain  and  stiffness,  without  swelling,  in 
the  left  knee.  On  February  13th  she  fell  and  injured  the  knee.  Her 
physician  said  that  she  had  sprained  it.  Since  then  there  has  been  little 
swelling,  but  considerable  pain.  After  three  days  in  bed  she  got  up  and 
hobbled  around  with  a  crutch,  the  knee  being  somewhat  stiff,  but  not 
painful,  until  two  weeks  ago,  when  pain  and  swelling  commenced 
and  have  confined  her  altogether  to  bed  for  the  last  six  days.  During 
the  last  two  weeks  she  has  had  occasional  night-sweats  and  nose-bleeds. 
Her  appetite  is  poor,  and  her  bowels  constij)ated. 

The  chest  and  abdomen  showed  nothing  al^normal.  The  reflexes 
were  all  present.  The  l^lood  and  urine  were  blameless;  there  was  no  fe\X'r. 
The  left  knee  was  found  to  be  swollen  and  flexed  to  an  angle  of  70 
degrees.  Its  circumference  was  I4  inches  greater  than  the  right  knee. 
■Most  of  the  swelling  was  on  the  anterior  surface,  and  there  was  a  sug- 
gestion of  |)osterior  subluxation  of  the  lower  leg.  The  skin  o\er  the 
knee  was  brownish,  shiny,  and  slightly  warmer  than  the  right.  There 
was  some  induration  and  some  infiltration,  with  moderate  tenderness  on 
pressure.     All  attempts  at  motion  caused  extreme  i)ain. 

Discussion. — Although  there  is  much  in  the  history  j)ointing  to 
a  traumatic  cause  for  this  pain,  the  severity  and  long  duration  of  the 
symptoms  argue  something  more  serious. 

Septic  osteomyelitis  has  generally  a  more  sudden  onset,  produces 
severer  pain,  disability  and  fe\cr.  This  patient  has  had  night-sweats. 
but,  so  far  as  we  are  aware,  no  fe\er. 

Tuberculous  osteomyelitis  might  |)roduce  almost  exactly  this  ])icture, 
though  it  would  probal)ly  be  accompanied  l)y  more  fe\er  and  less  pain. 
.\fter  so  long  a  duration  one  would  rather  expect  some  sinus  ftn'matinn. 
but  this  does  not  always  occur,  ^\'ithout  .v-ray  evidence  wc  cannot 
either  affirm  or  exclude  tuberculosis. 

Were  there  any  evidence  of  si)inal  disease  ftabes,  syringoniyrlia  \ 
one  might  suspect  a  Cliarcot  joint,  thougli  sucli  joints  are  usually  juiin- 
less.  But  in  this  case  there  is  no  evidence  of  the  ])riniarv  disease  \'>  lienet' 
Charcot's  joint  ])rocee(ls. 

oMalignant  disease  of  the  bone — ])resumal)l}"  -iareoma — would  account 


384 


DIFFERENTIAL  DIAGNOSIS 


for  all  the  symptoms  in  the  case.  Between  this  and  tuberculosis  the  diag» 
nosis  must  remain  in  doubt  on  the  basis  of  the  data  here  presented. 

Outcome. — X-ray  examination  showed  extensive  destruction  of  the 
lower  end  of  the  femur,  with  a  fracture  just  above  the  condyles.  June 
13th  the  leg  was  amputated  for  sarcoma  of  the  femur. 

Diagnosis. — Sarcoma  of  the  femur. 

Case  199 

A  Russian  tailoress  of  seventeen  entered  the  hospital  July  13,  1907. 
Six  days  ago  her  right  knee  and  lower  thigh  became  slightly  swollen  and 
very  tender.  Since  then  she  has  felt  a  little  chilly,  and  has  had  a  poor 
appetite,  but  no  other  symptoms  of  any  kind. 

The  course  of  the  patient's  temperature  is 
shown  in  the  accompanying  chart. 

Physical  examination  of  the  internal  viscera 
showed  nothing  abnormal.  The  right  knee  was 
red,  very  tender,  slightly  swollen.  The  white 
cells  ranged  between  8000  and  11,400.  The 
urine  was  about  normal  in  amount  and  in  weight. 
There  was  no  albumin,  but  a  few  hyaline  and 
finely  granular  casts  were  found.  Widal's  reaction 
was  negative.  On  the  eighteenth  the  knee  was 
less  tender,  but  larger  and  the  thigh  was  also 
swollen. 

Bier's  treatment  was  given,  one  hour  off,  two 
hours  on,  night  and  day,  without  much  relief. 

Discussion. — We  are  dealing  with  a  mon- 
articular inflammation  which  has  involved  also 
the  soft  parts  in  the  vicinity  of  the  joint.  Such  a 
condition  is  never  rheumatic,  and  the  atrophic 
and  hypertrophic  varieties  may  also  be  excluded,  because  they  are 
practically  never  confined  in  febrile  cases  to  a  single  joint. 

Gonorrhea  is  perhaps  the  commonest  cause  of  monarticular  inflam- 
mation, but  such  infections  are  very  rare  in  the  young,  unmarried  Russian 
Jewesses  of  Boston.  The  patient  had  no  vaginal  discharge,  and  there 
was  nothing  else  about  her  to  make  us  suspect  gonorrhea.  Neverthe- 
less, this  infection  cannot  be  positively  excluded.  The  course  of  the 
disease  is  too  acute  and  too  painful  for  tuberculous  osteitis. 

To  obtain  any  further  light  on  the  subject  the  joint  should  be  as- 
pirated under  asei)tic  precautions,  as  may  be  very  easily  done  with  an 
ordinary  hypodermic  needle.     In  my  opinion  joint  puncture  is  far  too 


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Fig.     72. — Chart 
case    199. 


PAIN  IN  THE  LEGS  AND  FEET  385 

rarely  performed.  If  done  with  rigid  cleanliness,  it  has  no  dangers, 
produces  scarcely  any  pain,  and  often  gives  us  information  of  the  highest 
value.  Since  I  have  been  in  the  habit  of  using  this  procedure  frequentlv 
I  have  been  astonished  to  see  how  commonly  one  finds  turbid  or  purulent 
exudates  with  demonstrable  micrococci  in  joints  which  have  been  onlv 
moderately  painful,  and  would  certainly  have  been  classed  under  or- 
dinary rheumatism  but  for  the  puncture.  In  some  cases  our  treatment 
is  made  far  more  effective  when  the  joint  puncture  makes  it  possible  to 
prepare  a  ^•accine  from  the  in\ading  organism. 

Outcome. — On  the  twentieth  the  right  knee  was  aspirated  and  six 
ounces  of  fluid  pus  withdrawn.  From  this  as  well  as  from  the  circulat- 
ing blood  a  pure  culture  of  the  yellow  staphylococcus  was  obtained. 
On  the  twenty-third  the  knee  was  surgically  drained.  Recovery  followed, 
though  there  was  limitation  of  motion  in  the  knee. 

Diagnosis. — Septic  knee. 

Case  200 

A  waiter  of  twenty-four  entered  the  hospital  December  29,  1906. 
He  had  been  in  the  hospital  twice  previously  for  exophthalmic  goiter. 
The  last  time  was  in  May,  1905.  Since  then  he  has  worked  steadily  at 
hard  jobs  and  has  felt  well.  Four  nights  ago  he  came  home  with  a  })ain 
in  his  left  instep.  The  next  day  the  pain  extended  u])  the  leg,  and  in  the 
afternoon  was  in  both  knees.  It  confined  him  to  bed  and  took  away 
his  appetite.     In  October  he  weighed  150  pounds — a  week  ago,  130. 

Physical  examination  showed  both  eyes  slightly  prominent.  The 
pulse  ranged  between  90  and  100.  Examination  was  otherwise  negative 
except  for  spasm  of  the  leg  muscles,  l^oth  legs  lacing  held  flexed.  I'he 
patient  insisted  at  first  that  they  could  not  be  moved,  but  was  finally 
induced  to  straighten  them  out.  Tater,  the  right  hand  was  held  xery 
stiflfly,  with  the  thumb  flexed  into  the  palm.  The  ])atient  persisted  that 
it  too  was  paralyzed,  but  was  finally  ])ersuaded  that  it  was  normal. 

Discussion, — The  pain  is  probably  due  to  muscular  spasm,  as  in 
the  familiar  cramps  most  of  us  have  ex])erienced  if  the  foot  or  leg  is  bent 
in  an  unusual  ])osition.  We  can  hardly  dou])t  that  these  cramps  are  of 
the  functional  or  hysteric  tv]ie,  in  view  of  the  results  of  moral  suasion, 
but  it  is  im])ortant  to  remember  that  a  latent  tuberculosis,  recogni/ablf 
only  by  :v-ray,  may  j)ro(luce  contractures  of  the  legs  fully  as  seviTc  as 
those  here  described.  If  the  contractures  were  not  so  wide  sjiread.  onv 
might  sus[)ect  flat-foot  with  leg  pains  due  to  com])ei"isatory  effort.  The 
onset  of  the  case  reminds  us  distinctly  of  this  lesioii.  but  its  lau-r  course 
makes  this  verv  unlikelv. 


386  DIFFERENTIAL  DIAGNOSIS 

The  case  illustrates  the  importance  of  firmness  and  confidence  in  our 
treatment — a  confidence  such  as  can  be  based  only  on  the  conviction  built 
up  in  us  by  most  painstaking  physical  examination  and  interrogation  of 
the  patient.  Any  doubt,  vacillation,  or  hesitation  in  the  management  of 
such  a  case  may  lead  to  disastrous  results.  Decisive  action,  on  the  other 
hand,  may  be  of  incalculable  benefit  to  the  patient  by  nipping  hysteric 
tendencies  in  the  bud.  Like  so  many  other  diseases,  hysteria  can  be 
checked  most  often  and  most  effectually  in  the  incipient  stages. 

Outcome. — -A  liberal  diet  with  30  grains  of  bromid  every  four  hours 
for  two  days,  preceded  by  an  ounce  of  castor  oil  at  the  time  of  entrance, 
was  followed  by  marked  improvement.  By  the  third  of  January  the 
patient  seemed  practically  w^ell.  He  had  still,  however,  a  slight  fine 
tremor  of  the  hands,  a  remnant,  no  doubt,  of  his  hyperthyroidism. 

Diagnosis. — Hysteria. 

Case  201 

A  housewife  of  forty-four,  who  has  had  two  miscarriages,  one  child 
of  nine  years  and  one  of  five,  entered  the  hospital  December  5,  1906. 
She  herself  was  born  with  crooked  legs,  which  were  straightened  by 
splints  at  her  home  in  Sweden.     She  has  had  pneumonia  four  times. 

Nine  years  ago  she  had  bad  pains  in  her  shoulders  and  arms,  so 
that  she  could  not  raise  her  hands  to  her  head.  At  that  time  lumps 
came  out  upon  her  arms,  and  ever  since  then  she  has  had  fleeting  pains, 
now  in  one  place,  now  in  another.  Thirteen  days  ago  she  was  wakened 
out  of  sleep  by  pain  in  her  feet.  Now  the  pain  comes  suddenly  and 
lasts  from  two  to  ten  or  more  minutes,  often  shooting  from  the  hips  to  the 
knees.  It  is  almost  as  sharp  as  labor  pain  at  times,  and  is  accompanied 
by  a  dragging-down  sensation.  Her  feet  have  been  a  little  swollen. 
There  has  been  some  dyspnea  on  exertion  and  a  little  cough  without 
sputa.  She  has  attacks  of  rapid  heart  action  almost  e\cry  day.  Five 
days  ago  she  fainted,  and  had  to  sit  up  in  bed  all  that  night.  Her 
appetite  is  poor,  her  l)owels  regular.     There  has  been  no  nocturia. 

The  patient  was  a  neurotic-looking  individual,  and  constantly 
demanded  attention  to  trivial  wants.  The  pupils  were  irregular,  but 
reacted  normally.  The  uvula  was  missing,  and  replaced  by  a  white 
scar;  the  throat  and  lungs  otherwise  normal.  The  glands  were  palpable, 
but  not  enlarged,  in  the  neck,  axilla^,  and  groins.  Occasional  squeaks 
were  heard  scattered  through  both  lungs.  The  chest  was  otherwise 
negative;  likewise  the  abdomen,  blood,  and  urine.  The  shafts  of  both 
tibic'e  were  enlarged  and  bowed  forward,  their  surface  rough  and  nodular. 
The  deep  reflexes  were  all  present. 


PAIN  IN  THE  LEGS  AND  FEET  387 

On  both  forearms,  especially  on  the  extensor  surfaces,  there  were 
a  dozen  nodules  from  the  size  of  a  pea  to  half  a  horse-chestnut.  They 
were  oyster-shaped,  discrete,  of  rubber}'  consistency,  not  tender,  freely 
movable  under  the  skin.     Vaginal  examination  was  negative. 

Discussion. — Fleeting  pains  in  various  parts  of  the  body  are  often 
the  most  distressing  symptom,  and  the  earliest,  in  tabes  dorsalis.  The 
history  of  miscarriages  and  the  tibial  deformities  increase  the  proba- 
bility of  syphilis,  and,  therefore,  of  tabes.  But  this  disease  may  be 
ruled  out  of  consideration  because  of  the  fact  that  the  pupils  and  the 
deep  reflexes  are  normal. 

The  patient's  statement  that  her  legs  were  crooked  from  birth 
makes  us  hesitate  to  attribute  the  present  condition  of  the  shins  to 
syphilis,  and  as  the  patient  has  two  healthy  children,  the  miscarriages 
may  well  have  had  a  non-syphilitic  origin.  But  the  scar  in  the  soft 
palate  and  the  absence  of  the  uvula  are  decidedly  more  characteristic 
of  syphilis,  and  in  any  patient  who  presents  such  lesions  we  must  do  our 
best  to  find  any  connection  that  may  exist  between  the  old  infection 
and  the  present  symptoms.  Very  possibly  tlie  vascular  lesion  so  com- 
monly produced  b}'  syphilis  may  be  connected  with  the  pains  here 
complained  of.  "  \'ascular  crises  "  are  certainly  more  common  in  those 
who  have  suffered  a  luetic  infection,  and  through  such  crises,  with  or  with- 
out a  syi)hilitic  neuritis,  the  pains  of  this  patient  might  be  accounted  for. 

We  must  also  consider,  however,  the  nodules  present  u])on  the  fore- 
arms and  mentioned  in  the  history  as  haN'ing  appeared  nine  years  earHer. 
The  fact  that  these  tumors  have  lasted  so  long  makes  it  sure  that  they 
are  not  of  a  malignant  type,  and  their  limited  distribution  assures  us 
that  they  are  not  connected  with  the  much  more  widely  distril)uted 
pain  of  which  the  patient  complains.  Their  physical  characteristics 
are  those  of  li])omata,  which  are  ])ractically  the  only  tumors  which 
could  last  so  long  without  more  disastrous  effects. 

Outcome. — The  patient  was  gi\cn  mercury  and  [jotassium  iodid. 
Her  leg  ])ains  were  greatly  relie\ed  by  injections  of  sterile  water,  especi- 
ally in  the  first  two  days  after  entrance.  The  lumps  on  the  arms  were 
taken  to  be  fatty  tumors. 

She  was  discharged  much  relieved  on  the  twelfth  of  December. 

Diagnosis. — Sy])hilis. 

Case  202 

An  engineer  of  forty-fixe  cnleTcd  the  hospital  July  25.  1006.  His 
family  history  was  negative.  He  had  urethritis  twenty  years  ago,  al><) 
five  weeks  a<jro.  the  latter  attack  followed  Iw  "  rlioiniatisni.''     He  had 


388  DIFFERENTIAL  DIAGNOSIS 

"slow  fever  "  twenty  years  ago,  and  was  five  weeks  in  bed.  Ten  years 
ago  he  had  inflammatory  rheumatism,  lasting  three  weeks,  in  both  feet. 
No  other  parts  were  affected.  He  takes  an  occasional  glass  of  beer, 
but  denies  any  other  use  of  alcohol.  Eleven  days  ago  his  left  foot 
became  red,  swollen,  and  tender.  This  gradually  improved,  but  yester- 
day the  right  foot  became  similarly  affected.  He  has  been  unable  to 
work  since  the  onset  of  the  symptoms.  He  has  had  a  poor  appetite, 
constipation,  slight  headache  and  fever. 

The  patient  was  obese,  slightly  cyanotic.  The  first  sound  at  the 
apex  of  the  heart  was  replaced  by  a  short  systolic  murmur,  not  trans- 
mitted. The  aortic  second  sound  was  accentuated,  the  heart  not  en- 
larged. The  lungs  were  normal,  likewise  the  abdomen,  except  for 
dulness  in  the  right  flank,  which  does  not,  however,  shift  with  change 
of  position.  The  second  joint  of  the  right  toe  was  much  swollen,  hot, 
and  tender.  The  same  joint  in  the  other  foot  was  similarly  affected, 
but  the  swelling  also  extended  up  the  foot  toward  the  ankle. 

Discussion. — In  any  patient  who  complains  of  subacute  pain  in 
both  feet,  and  is  not  flat-footed,  suspect  gout.  Most  of  the  ordinary 
joint  infections  do  not  long  remain  confined  to  the  feet,  while  gout  is 
very  prone  to  do  so. 

Naturally,  however,  the  first  possibility  to  be  investigated  in  this 
patient  is  gonorrhea,  as  he  had  so  recently  suffered  from  that  infection. 

Next  we  must  search  the  cartilages  of  the  ears  and  nose,  the  great 
tendons  near  the  elbow  and  ankle,  and  the  vicinity  of  the  great  toe-joints 
for  signs  of  uratic  deposit.  Thirdly,  we  must  investigate  the  plantar 
arches,  since  precisely  these  symptoms  might  be  produced  by  flat-foot. 
Other  infectious  and  non-infectious  lesions  are  far  less  probable. 

Outcome. — A  smear  from  the  urethra  showed  a  biscuit-shaped 
diplococcus  both  within  and  without  the  leukocytes.  It  did  not  stain 
by  Gram's  method.  The  ears  showed  several  small,  yellowish-white, 
soft  lumps.  A  scraping  from  one  of  these  showed  crystals  correspond- 
ing to  those  of  sodium  biurate.  X-ray  showed  areas  of  atrophy  or 
erosion  of  the  second  phalanx  of  one  great  toe,  which  were  believed  by 
an  :x:-ray  expert  to  be  due  to  gout. 

By  the  sixth  of  August  the  patient  was  practically  comfortable. 
His  treatment  had  consisted  of  sodium  salicylate,  20  grains  every  hour 
for  the  first  two  days,  then  10  grains  every  hour.  Hot  fomentations 
applied  to  the  painful  parts,  an  ounce  of  magnesium  sulphate  e^'ery 
morning,  10  grains  of  urotropin  four  times  a  day.  He  was  not  in  bed 
after  the  twenty-ninth,  and  was  discharged  relieved  on  the  sixth  of 
August. 

Diagnosis.— Gout  and  gonorrhea. 


PAIN    IN    THE   LEGS    AND    FEET 


389 


Case  203 

A  restaurant-keeper  of  forty-nine  entered  the  hospital  September 
18,  1907.  His  mother  died  at  seventy-two,  after  suffering  from  consump- 
tion for  fifteen  years.  The  patient  has  had  "  rheumatism  "  in  his  joints 
in  two  attacks  of  three  weeks  each — three  years  ago  and  eighteen  months 
ago.  He  has  had  four  attacks  of  urethritis,  the  last  twenty-five  years 
ago,  but  denies  syphilis. 

He  says  that  he  was  as  strong  as  an  ox  until  four  years  ago,  when  he 
sold  his  business  and  had  difficulty  in  getting  a  new  start.  He  then 
began  to  have  almost  constant  pain  near  the  right  costal  margin.  These 
symptoms  he  has  had  off  and  on  ever  since.  He  has  rather  frequent 
attacks  of  vertigo  and  weakness,  and  his  appetite  is  often  poor.  As 
long  as  he  can  remember  his  fin- 
gers have  been  clubbed,  as  they 
are  at  present.  He  usually  takes 
two  glasses  of  beer  and  two  or 
three  of  whisky  a  day,  and  his  use 
of  tobacco  is  distinctly  excessive. 
Yesterday  he  noticed  that  the 
corners  of  his  mouth  cracked.  Off 
and  on  for  four  years  he  has  felt 
feverish,  and  sometimes  chilly  and 
shivery  in  the  evenings.  His  knees 
and  ankles  have  burned,  especially 
after  he  gets  to  bed. 

These  joint  symptoms  have  been 
getting  steadily  worse,  and  two 
days  ago  he  had  to  give  up  and 
go  to  bed  on  account  of  pain  in 
his  legs  and  kni'cs.  Yesterday 
the  right  knee  became  a  little 
better,  the  left  worse.  At  the  same  time  his  left  thumb  began  to  l)c  red, 
swollen,  tender  and  painful.      This  time  he  had  true  cliill. 

Physical  examination  showed  that  the  left  ])upil  was  larger  than  the 
right,  though  l)()th  reacted  normally.  Tlie  licart  was  normal.  I'ln-re 
was  slight  dulness  ])elow  the  right  sca|)ula,  with  slight  increase  of  vcxal 
and  tactile  fremitus,  and  a  few  rales.  Ex])iration  was  e\erywherr  rough 
and  ])rolonge(l.  The  abdomen  was  negative.  The  right  kni'f  was 
swollen,  hot  and  shiny;  the  leg  was  ke]it  l)ent  at  a  riglit  angh',  and 
motion  was  ]minful.    A  similar  condition  was  fovmd  in  the  right  foot  and 


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39°  DIFFERENTIAL   DIAGNOSIS 

ankle.  Both  feet  were  pronated.  There  was  marked  dubbing,  cyanosis, 
and  curvature  in  both  planes  in  the  fingers  and  thumbs,  and  to  a  less 
degree  in  the  toes.  Scattered  over  the  chest  and  back  was  a  reddish- 
brown,  macular  eruption,  the  spots  about  the  size  of  the  little  finger-nail. 

Discussion. — There  seems  to  be  no  way  by  which  we  can  connect 
the  mother's  consumption  or  the  patient's  alcoholism  with  the  present 
symptoms.  The  joints  are  obviously  not  tuberculous,  and  alcohol  does 
not  attack  articular  structures. 

Though  it  would  be  natural  to  connect  the  former  attacks  of  ure- 
thritis with  the  present  joint  pains,  the  gap  of  twenty-five  years  between 
the  two  renders  this  impossible  if  the  history  is  taken  on  its  face  value. 
In  looking  over  the  body  for  any  other  lesion  which  we  can  connect  with 
the  joint  symptoms,  we  notice  the  irregular  pupils,  the  clubbed-fingers, 
and  the  cutaneous  eruption. 

If  the  clubbing  of  the  fingers  be  assumed  to  be  such  as  is  described, 
it  is  not  likely  to  have  any  connection  with  the  arthritis.  Bony  out- 
growths near  the  finger-ends  (Heberden's  nodes)  bear  some  resemblance 
to  clubbed-fingers,  but  could  hardly  be  mistaken  for  them.  Such  out- 
growths, if  present,  might  incline  us  to  conjecture  that  the  right  knee 
and  ankle  were  the  seat  of  a  similar  process. 

The  irregular  pupils  and  the  cutaneous  eruption  look  like  syphilis, 
and  since  there  is  nothing  very  definite  known  about  the  differential 
symptomatology  of  syphilitic  arthritis,  it  seems  reasonable  to  interpret 
the  joint  manifestations  in  this  case  as  syphilitic  until  this  is  disproved 
by  therapeutic  test.  If  no  improvement  follows  the  vigorous  use  of 
mercury  and  iodin,  the  joint  should  be  tapped  in  search  of  some  other 
infective  agent. 

Outcome. — Under  daily  inunctions  of  mercury  and  the  administra- 
tion of  potassium  iodid — lo  grains  after  each  meal — the  joints  rapidly 
improved,  and  within  ten  days  were  practically  ^^■ell. 

The  clubbing  of  the  fingers  remains  in  this,  as  in  many  other  cases, 
a  mystery.  If  clubbing  were  more  carefully  searched  for  as  a  matter  of 
routine  in  cases  presenting  no  pulmonary  or  cardiac  lesions,  it  would 
be  found,  I  believe,  to  occur  in  a  great  variety  of  diseased  conditions  and 
in  a  good  many  persons  who  have  no  demonstrable  disease.  Personally, 
I  have  obser\-ed  it  chiefly  in  chronic  diseases  of  the  liver  ('cirrhosis,  ab- 
scess, gall-stone  disease),  in  tuberculous  peritonitis,  and  in  ill-nourished 
children. 

Its  occurrence  in  connection  with  long-standing  cardiac  disease  (con- 
genital or  acquired),  with  chronic  pleurisy  or  empyema,  phthisis  and 
bronchiectasis,  is,  of  course,  familiar. 

Diagnosis. — Syphilis. 


PAIN  IN  THE  LEGS  AND  FEET  39I 

Case  204 

A  plumber  of  thirty-seven  entered  the  hospital  April  n,  1908.  He 
drinks  and  smokes  to  excess.  Last  evening  he  came  home  complaining 
of  severe  pain  in  both  legs,  especially  in  the  left  one.  Aljout  one  o'clock 
this  morning  he  awoke  unable  to  speak  or  to  move  the  right  arm  and 
leg.  Soon  after  the  patient  became  unconscious,  with  stertorous  breath- 
ing. 

The  right  forearm  was  in  flexion,  the  fingers  of  the  right  hand  flexed 
and  spastic,  the  mouth  drawn  to  the  left;  he  made  onlv  inarticulate 
sounds.  .  The  right  leg  was  spastic.  By  April  13th  he  had  regained  con- 
sciousness and  he  could  move  the  toes  slowly;  otherwise  he  had  no  mus- 
cular control.  His  tongue  came  out  to  the  right  when  protruded.  There 
was  no  lead  line.  The  chest  and  abdomen  showed  nothing  abnormal. 
The  blood-pressure  was  155,  the  blood  and  urine  normal,  the  right  knee- 
jerk  lively  in  comparison  with  the  left  knee-jerk.  There  were  no  other 
changes  in  the  reflexes  at  this  time. 

By  April  15th  Babijiski's  reflex  had  appeared  in  the  right  foot. 
Lumbar  puncture  was  done  on  the  seventeenth,  and  the  cells  in  the  fluid 
which  was  withdrawn  were  50  to  the  cubic  millimeter.  Practically 
all  of  them  were  lym])hocytes. 

Discussion. — The  patient's  occupation  naturally  leads  us  to  attem]>t 
to  explain  the  symi)toms  as  a  result  of  lead-poisoning,  especially  as 
paralysis  and  cerebral  sym|)toms  are  present.  But  we  do  not  expect 
pain  or  hemiplegia  in  plumbism,  and  we  practically  always  find  changes 
in  the  staining  properties  of  the  red  blood-corpuscles. 

Against  apoplexy,  which,  as  the  commonest  cause  of  hemijjlcgia, 
naturally  occurs  to  us  next,  is  the  patient's  age,  the  very  moderate 
blood-pressure,  the  absence  of  cardiac  hy])ertrophy,  and  es])ccially 
the  results  of  lumbar  ])uncture. 

The  examination  of  the  spinal  fluid  taken  in  connection  with  the 
absence  of  fe\er  and  the  well-marked  cerebral  s} mj)toms  lead  us  straight 
to  the  diagnosis  of  cerdjrospinal  syphiHs.  A  similar  lymj)hocyt()sis 
occurs  in  the  chronic  forms  of  meningitis,  esi)ecially  tuberculous  menin- 
gitis, but  the  clinical  ])icture  is  quite  different  from  that  here  under 
consideration. 

The  most  interesting  point  in  this  case  is  the  occurrence  ot  a  jiain 
which,  though  referred  to  the  legs,  seems  to  be  cerebral  or  spinal  in  oiiirin. 
Such  j)ains  are  seen  not  uncommonl}-  in  infantile  ])aral\sis.  in  some  of 
the  types  of  acute  myelitis  and  nienin^Mtis,  and  t'sneiiall\"  in  cenbro- 
spinal   svphilis.     1   reeentlv  studied  a  case   in   which   atiacks  ot    Jack- 


392 


DIFFERENTIAL   DIAGNOSIS 


sonian  epilepsy,  involving  the  right  hand  and  forearm,  were  preceded, 
again  and  again,  by  severe  pain  referred  to  the  parts  about  to  be  con- 
vailsed.  Many  of  these  central  pains  are  preceded  or  accompanied  by 
paresthesia. 

Outcome. — Under  mercury  and  potassium  iodid  the  patient  was 
able  to  walk  by  the  twenty-second,  though  his  mind  was  still  very  sluggish. 
The  next  day  he  was  sent  to  a  State  infirmary. 

Diagnosis. — Cerebrospinal  syphilis  (vascular  crisis?). 

Case  205 

A  machinist  of  thirty-nine  entered  the  hospital  May  29,  1908.  His 
father  died  of  apoplexy,  his  mother  of  dropsy.  Seven  years  ago  he  was 
in  bed  five  days,  owing  to  swelling,  redness   and  pain  in  the  left  knee. 


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In  the  past  five  years  he  has  had  tonsillitis  six  or  eight  times,  once 
seA'erely  enough  to  keep  him  in  bed.  He  had  urethritis  twenty-three 
years  ago. 

He  takes  two  or  three  glasses  of  whisky  and  two  or  three  of  beer  each 
week.  Two  weeks  ago  he  had  a  sudden  chill  accompanied  by  pain 
in  the  lower  back,  in  the  hands  and  the  calves  of  his  legs.  He  took  to 
bed  and  has  been  there  since,  with  persistent  fever.  The  next  morn- 
ing his  right  knee  and  the  joints  of  the  left  hand  were  painful  and  stiff. 


PAIN  IN  THE  LEGS  AND  FEET  393 

Six  days  ago  the  knee  became  red  and  swollen,  while  the  left  hand 
greatly  improved. 

He  has  had  no  urinary  symptoms;  his  appetite  has  been  good; 
his  bowels  regular;  there  has  been  no  sore  throat  and  no  cough. 
The  course  of  the  temperature  may  be  seen  in  the  accompanying  chart. 

The  chest  and  abdomen  were  negative,  the  knee-jerks  normal; 
the  plantar  reflexes  were  not  obtained.  There  was  no  glandular  en- 
largement. The  right  knee  was  flexed  at  an  angle  of  45  degrees,  any 
motion  causing  severe  pain;  all  the  evidences  of  fluid  were  found  in  the 
joint. 

Discussion. — As  in  many  of  the  cases  discussed  in  this  section, 
we  have  here  a  general  infection  which  shows,  at  first,  no  hint  of  its 
ultimate  localization. 

Since  the  urethritis  occurred  too  long  ago  for  us  to  connect  it  with 
the  present  symptoms,  it  seems  at  first  likely  that  the  joint  trouble 
may  be  due  to  the  patient's  repeated  attacks  of  tonsillitis,  and  as  gout 
and  traumatism  can  be  excluded  by  the  lack  of  any  evidence  of  them, 
tonsillitis  would  perhaps  be  the  best  guess  we  could  make,  were  we 
debarred  from  any  further  and  more  direct  investigations.  But,  as 
I  have  previously  insisted,  all  monarticular  infections  of  any  serious- 
ness or  obstinacy  should  be  tapped,  since  the  information  thus  to  be 
derived  may  be  of  the  greatest  therapeutic  value.     (See  p.  385.) 

In  all  probability  the  infecting  organism  is  one  of  the  pyogenic 
cocci,  but  it  may  be  of  great  importance  to  know  which,  as  a  treatment 
by  autogenous  vaccines  has  much  to  recommend  it. 

Outcome. — On  the  first  of  June  the  joint  was  aspirated  and  35  cm. 
of  fluid  withdrawn.  Specific  gravity,  1008;  albumin,  3.6  ])cr  cent.; 
in  the  sediment,  94  per  cent,  of  the  cells  were  polynuclear.  Among 
them  were  numerous  intracellular  di])lococci  which  did  not  slain  by 
Gram's  method.  After  this  information  had  been  obtained,  the  ])aticnl 
admitted  a  urethritis  ten  weeks  ago,  but  insisted  that  there  had  been 
no  discharge  for  the  past  four  weeks.  PVom  tlie  fluid  witiidrawn  from 
the  joint,  gonococci  were  isolated  in  pure  culture.  From  this  a  Micciiu- 
was  ])repared  and  injected.  He  improved  quite  ra])idly  after  this,  and 
by  the  sixteenth  was  able  to  go  to  the  Zander  room  daily. 

On  the  twenty-fourth  the  knee  was  smaller  and  much  more  com- 
fortable. Bier's  treatment  was  gi\en  after  that  date,  and  he  was  s(m>ii 
taught  to  a])])ly  it  for  himself.  On  the  fourth  of  July  he  was  disib.argid. 
much  relieved. 

Diagnosis. — Gonorrheal  arthritis. 


394  DIFFERENTIAL   DIAGNOSIS 

Case  206 

A  metal  worker  of  fifty  entered  the  hospital  March  27,  1908,  stating 
that  he  had  never  been  sick  before,  and  giving  a  good  account  of  his 
habits.  Se\en  weeks  ago,  while  at  work,  he  was  taken  with  a  sudden 
chill  and  went  home  and  to  bed.  In  the  night  he  awoke  with  a  sharp 
pain  in  the  right  shoulder  and  the  left  knee.  He  managed  to  get  to 
sleep,  however,  and  was  much  surprised  to  find  the  next  morning  that 
the  pain  had  left  the  shoulder,  but  that  the  knee  was  hot  and  swollen, 
painful,  red  and  tender.  The  knee  has  increased  in  size  since,  and 
he  has  been  confined  to  bed,  but  has  had  no  more  fever  or  chills  and 
no  pain  except  in  his  knee. 

On  physical  examination  the  patient  was  very  apprehensive  and 
emaciated;  there  was  a  moderate,  coarse  tremor  of  the  hands  and  feet; 
his  face  was  dusky  and  dark  under  the  eyes,  his  mucous  membranes  pale, 
though  his  leukocyte  count  was  80  per  cent.  His  heart's  apex  was  in 
the  fifth  space,  an  inch  outside  the  nipple-line.  The  sounds  were  rapid 
and  weak,  the  aortic  second  louder  than  the  pulmonic  second.  There 
was  no  enlargement  to  the  right  and  no  murmur.  The  pulses  were  of 
very  low  tension,  and  the  artery  wall  barely  palpable. 

The  lungs  were  negative;  the  abdomen  showed  considerable  volun- 
tary spasm  and  slight  dulness  in  the  extreme  flanks,  not  shifting  on 
change  of  position.  The  left  knee  was  markedly  enlarged,  tender,  hot, 
red  and  very  painful  on  motion.  The  swelling  was  most  marked  on 
the  front  of  the  knee,  but  extended  up  to  the  middle  of  the  thigh 
and  two  inches  below  the  tubercle  of  the  tibia.  The  front  of  the 
thigh  was  fluctuant,  tender,  and  covered  by  a  tracery  of  prominent 
veins.  A  fluid  wave  could  be  transmitted  from  the  knee  to  the  middle 
of  the  thigh. 

Discussion. — This  case,  though  very  similar  to  the  last,  is  given 
as  an  awful  example  of  what  may  result  from  the  neglect  of  early  joint 
]juncture  in  monarticular  arthritis.  It  is  a  sin  and  a  shame  that  this 
]jatient  should  have  gone  seven  weeks  without  any  eff'ective  etiologic 
or  radical  treatment.  From  the  facts  presented,  no  trained  observer 
could  doubt  that  there  is  pus  in  and  around  the  joint.  The  nature  of 
the  infection  is  the  only  remaining  diagnostic  problem. 

Outcome.— On  the  twenty-seventh  the  knee  was  tapped  and  thick 
I)us  obtained.  A  culture  from  this  pus  showed  streptococci.  On 
March  28th  the  knee  was  opened  and  almost  a  quart  of  pus  obtained, 
which  apparently  came  from  outside  tlie  knee-joint.  The  ])atient  ran 
a  jagged,   septic  temperature  for  a  month,  and  (le\elopc(l  a  metastatic 


PAIN    IN    THE   LEGS   AND    FEET  395 

abscess  in  the  axilla,  whence  a  colon  bacillus  was  obtained.     Despite 
amputation,  he  finally  died. 
Diagnosis. — Sepsis. 

Case  207 

A  physician  forty-six  years  of  age  entered  the  hospital  June  5,  1906. 
He  had  a  primary  lesion  on  his  thumb  one  year  ago;  a  secondary  eruption 
with  adenitis  and  sore  mouth  followed.  A  thorough  antisyphilitic 
treatment  has  been  given  since.  Two  weeks  ago  a  swelling  appeared  in 
the  left  foot.  Within  a  few  days  the  soles  of  both  feet  became  red, 
swollen  and  tender.  Ten  days  ago  he  was  laid  up  in  bed  for  three  da}'s. 
In  every  other  way  he  is  perfectly  well. 

Physical  examination  showed  considerable  irregularity  of  the  pupils, 
but  was  otherwise  negati\e  except  as  relates  to  the  left  foot,  which  was 
red,  tender  and  slightly  swollen  over  the  dorsum  and  on  the  sole  opposite 
the  head  of  the  second  metatarsal  bone. 

Discussion. — It  is  difficult  to  decide  whether  the  syphilitic  infection 
of  a  year  ago  has  any  connection  with  this  patient's  present  suffering. 
It  seems  rather  imj)robabIe,  in  view  of  the  absence  of  s})ecif!C  lesions  at 
the  present  time. 

As  the  patient  has  now  no  fever,  one  naturally  thinks  of  flat-foot 
as  a  cause  of  such  foot-])ain,  e\"en  though  redness  and  tenderness  \vould 
otherwise  incline  us  to  assume  an  inflammation.  The  mutual  relations  of 
arthritis  and  flat-foot  have  been  previously  discussed.  (See  p.  366.) 
In  any  such  case  the  first  and  best  thing  to  do  is  to  try  t\\o  therapeutic 
tests:  (a)  The  effect  of  taking  the  patient  ofl"  his  feet,  and  ib)  the  ctTect 
of  padding  the  arches. 

Outcome. — Though  no  medicine  was  given,  the  pain  was  entirely 
gone  after  a  few  days'  rest,  and  as  soon  as  foot-plates  had  ])een  fitted,  the 
patient  was  able  to  walk  without  pain. 

\\c  have  still  on  our  hands,  however,  the  ([uestion:  ^\"hy  did  the 
arches  l)reak  down  just  at  this  lime?  I'ossibly  some  latent  and  un- 
recognized ])hase  of  his  old  syphilis  may  provide  the  answer. 

Diagnosis. —  Fhit  foot. 

Case  208 

A  laborer  of  f()rt\--se\en  entered  the  hos])ital  July  6,  i()o6,  con'i])lain- 
ing  of  sciatica.  He  had  a  similar  trouble  nine  \ears  ago,  which  la>U(l 
three  weeks.  Otherwise  he  has  been  well  until  se\en  months  ago.  w  lun 
lie  gradually  began  to  notice  ])ain  in  the  back  and  left  hip,  running 
down  the  left  thigh  behind  and  extending  into  the  calf.  He  has  I'.ad  tc 
gi\e  up  work,  but  has  walked  about  witli  a  marked  hnip. 


396  DIFFERENTIAL   DIAGNOSIS 

For  the  last  six  weeks  the  pain  has  been  much  worse  and  has  kept  him 
awake  at  night.  He  has  had  some  tingling  and  other  curious  sensations 
in  his  lower  left  leg.  He  has  lost  15  pounds  in  weight,  though  his  appe- 
tite is  good. 

Physical  examination  shows  that  the  patient  cannot  stand  erect, 
but  supports  himself  with  the  spine  curved  to  the  left  and  forward.  The 
motions  of  the  back  are  inhibited  by  a  pain  referred  to  the  sacro-iliac 
joint.  Full  extension  or  flexion  of  the  left  leg  is  impossible  on  account 
of  pain  referred  to  the  same  point.  There  is  tenderness  over  the 
region  of  the  left  sciatic  nerve  and  slight  atrophy  of  the  muscles  of  the 
left  leg,  making  about  one  inch  difference  in  the  circumference  of  the 
thighs  and  calves. 

Discussion. — In  the  out-patient  records  of  the  Massachusetts 
General  Hospital  previous  to  the  year  1900  there  are  to  be  found  notes  of 
a  large  number  of  cases  with  the  diagnosis  "lumbago  and  sciatica.'^ 
At  the  time  when  we  were  dealing  with  these  cases  it  always  seemed 
remarkable  to  me,  and  I  imagine  also  to  many  of  my  colleagues,  that  a 
disease  aff"ecting  a  muscle  (lumbago)  should  occur  simultaneously  with 
a  neuritis  (sciatica) .  The  case  reported  above  is  typical  of  a  great  many 
of  those  which  we  used  to  label  "lumbago  and  sciatica." 

Looking  at  it  from  the  point  of  view  of  the  present  day,  one  would 
say,  first  of  all,  that  the  lumbar  pain  has  lasted  too  long  for  lumbago, 
which,  like  other  muscular  pains,  is  a  transient  though  perhaps  recur- 
rent affair,  producing  its  symptoms  for  not  more  than  a  week  or  two  at  a 
time. 

The  other  half  of  the  old  diagnosis — sciatica — we  should  now  be 
unwilling  to  make  without  a  far  more  searching  investigation  of  the 
possible  causes  for  sciatic  pain,  especially  diabetes,  disease  of  the  lumbar 
spine  or  sacro-iliac  joint,  and  pelvic  tumors. 

The  present  case  is  fairly  typical  of  what  is  now  called  sacro-iliac 
strain,  a  diagnosis  based  most  firmly  upon  the  therapeutic  test — the 
means  by  which  it  is  relieved.  The  etiology  and  pathology  of  the  affec- 
tion are  still  very  oljscure,  and  the  theories  usually  advanced  do  not 
seem  satisfactory  to  me. 

Outcome. — The  patient  was  seen  l)y  Dr.  Goldthwait,  who  made  a 
diagnosis  of  "chronic  strain"  of  the  left  sacro-iliac  joint. 

The  pain  was  entirely  relieved  by  a  pillow  under  the  knee  and  a  folded 
sheet  under  the  lumbar  spine,  with  rest  in  bed.  A  plaster  jacket  was 
then  applied,  and  by  August  2d  he  was  free  from  pain  and  could  walk  a 
little.     On  that  day  he  was  discharged,  much  relieved. 

Diagnosis. — Sacro-iliac  strain. 


PAIN   m    THE   LEGS   AND   FEET 


397 


Case  209 


A  housemaid  of  twenty-five  entered  the  hospital  x\ugust  i6,  1907, 
stating  that  for  three  weeks  she  had  had  swelUng,  pain  and  tenderness 
in  the  lower  legs,  especially  at  night. 

Physical  examination  shows  yellowish  pallor  and  only  25  per  cent. 
of  hemoglobin;  the  white  cells  varied  between  28,000  and  43,000  in  the 
course  of  the  next  four  days,  the  polynuclears  making  up  82  per  cent. 
of  this  increase.      For  temperature  see  the  accompanying  chart. 

Physical  examination  was  negative  save  for  an  indefinite  resistance 
in  the  right  upper  quadrant  of  the  abdomen.  The  front  of  both  legs 
showed  numerous  sharply  defined,  punched-out  ulcerations  on  a  red- 
dened base;  the  right  lower  leg  showed  soft  nodules  the  size  of  a  i)ea, 
raised  one-half  inch  above  the  surround- 
ing skin,  covered  with  unbroken  skin. 
They  were  of  a  doughy  consistence  and 
tender. 

The  subcutaneous  ulcerations  were 
drained  by  surgical  incisions  and  con- 
siderable pus  liberated. 

Discussion.  —  Obviously,  we  are 
dealing  with  some  type  of  acute  infec- 
tion, the  most  probable  source  for 
which  seems,  at  first  examination,  to 
be  the  gall-bladder.  But  on  further 
scrutiny  it  is  equally  obvious  that  we 
need  some  source  for  the  very  marked 
and  ai)parently  chronic  anemia  which 
has  reduced  the  hemoglobin  to  25  per 
cent.'  In  cases  accompanied  by 
marked  secondary  anemia  I  have  found 
that  in  mo\ing  toward  a  diagnosis  it 
is  a   useful    strategic   maneiu'cr  to  fix 

attention,  first  of  all,  upon  this  anemia,  and  to  investigate  what  causes 
of  such  an  anemia  are  ])ossible  in  this  patient.  The  patient  may,  ot 
course,  be  chlorotic,  but  as  she  certainly  has  something  else  the  matter 
with  her,  we  must  make  two  diagnoses  (which  we  are  al\\a}s  loth  to 
do)  in  case  we  call  it  chlorosis. 


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-"«       ,  /■    L,  „     1  ■!.',.'//  i 

101-  ""V'tiws*  "■•■"■«•.«  .......... 

1 

» Z-               ' 

:  ,„.       _}    ^  J  ■ 

:  Z       t-.M 

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:  M-     1  /                *:  ^i\-»/r!  } 

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r-                                       -X 

M-                                                       i 

e 

^ 

m              ,          /i)^,f              ... 

z-jmMm^^-- 

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5^1  ,k.  J  *  iiX,  7» 

u                        4t:       '    i          '     1 

J;  '1        III. 

Z              V          1 

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:  _v.a^^.,'^>y 

.-    J4,;-,i,r.T-Ji.?',.i  ^-"t  ."U 

Fig.  75. — Chart  oi  caso  20Q. 


*  I  rc^'R't  that  no  estimation  of  ri-d  rclls  was  rcconlcd  in  this  1  asc.  It  was  cxidcn!, 
howcviT,  from  the  a]>i)i';iran(c  of  the  stained  smear,  lli.il  the\  were  u^ '•.  ^reaI!\  redu.  ed 
aiul  that  the  anemia  was  of  the  seiondary  type. 


398 


DIFFERENTIAL   DIAGNOSIS 


Aside  from  chlorosis,  what  are  the  possible  causes  of  a  severe  secon- 
dary anemia  in  a  woman  of  twenty-five  who  has  had  no  hemorrhage, 
no  malaria,  and  no  evidences  of  malignant  disease?  The  lesions  on 
the  shins,  and  especially  those  covered  with  unbroken  skin,  suggest 
gummata,  and  although  there  is  certainly  a  secondary  infection,  the 
hypothesis  of  syphilis  should  be  put  to  the  therapeutic  test. 

Outcome. — Microscopic  examination  of  an  excised  nodule  showed 
gumma  with  secondary  infection.  The  lesions  quickly  cleared  up 
under  antisyphilitic  treatment. 

Diagnosis. — Syphilitic  periostitis. 


Case  210 

A  hostler  of  thirty-two  was  first  seen  June  3,  1907.     He  takes  five 

or  six  beers  and  three  or  four  whiskies  daily,  but  denies  venereal  disease. 

Yesterday    morning  he  woke  with  a  chill  followed  by  headache,  fever 

and   aching  bones.     To-day  his  chief   com- 
plaint is  of  pain  in  his  legs. 

Physical  examination  of  the  chest  and  ab- 
domen is  negative.  The  right  tibia  is  rough 
and  nodular;  the  skin  bluish  red  and  con- 
taining three  ulcerated  areas  from  the  size  of 
a  silver  dollar  to  that  of  the  palm.  The  course 
of  the  temperature  and  pulse  is  seen  in  the 
accompanying  chart.  The  leukocytes  are 
12,500.  The  glands  in  the  right  groin  are 
enlarged;  urine  normal.  A'-ray  shows  evi- 
dences of  a  sy])hilitic  periostitis.  Under  large 
doses  of  iodid  of  potash,  the  glands  of  the 
groin  became  smaller  and  the  pain  disappeared 
within  ten  days. 

Discussion.  —  This  case  is  introduced 
chielly  to  show  the  importance  of  ;v-rav  ex- 
amination of  the  shin  bones  in  all  cases  in- 
\ol\ing  an  obscure  pain  referred  to  the  lower 

leg.     Without  the  evidence  thus  o])tained  a  diagnosis  would  here  have 

been  impossiljlc. 

Doubtless  there   was  also  a  certain  degree  of  secondary  infection 

in  the  ulcerated   area,   \vlience  the  chill,  high     fever  and  other  acute 

symptoms  may  be  explained. 

Diagnosis. — Syphilitic  periostitis. 


Fig.  76. — Chart  of  case 
210. 


PAIN  IN  THE  LEGS  AND  FEET 


399 


Case  211 

A  shoemaker  of  nineteen  entered  the  hospital  May  14,  1908,  with 
a  good  family  history,  past  history  and  habits.  Three  days  ago  he 
began  to  have  pain  in  his  legs  and  to  a  lesser  extent  in  his  left  side.  At 
night  he  vomited  twice  and  has  since  kept  his  bed.  The  pain  has  been 
more  severe  in  his  chest,  until  to-day,  when  it  has  diminished.  He 
has  slept  and  eaten  poorly  and  has  been  constipated.  He  has  had  no 
cough  and  no  chill. 

Physical  examination  showed  dulness  in  the  lower  half  of  the  left 
back,  with  bronchial  breathing;  increased  voice  and  fine,  crackling  rales. 

The  leukocytes  were  22,000.  The  urine  and  the 
rest  of  the  physical  examination  were  normal.  The 
course  of  the  temperature  is  shown  in  the  accom- 
panying chart.  A  tight  swathe  prevented  all  pain. 
On  the  nineteenth  he  was  put  in  a  chair,  and  by 
the  twenty-fifth  was  able  to  go  to  his  home. 
Throughout  his  illness  he  had  practically  no  cough 
or  expectoration. 

Discussion. — This  case  is  introduced  in  order 
briefly  to  exemplify  a  pain  due  to  general  infection, 
but  confined  to  the  legs.  Some  of  these  pains  are 
very  mysterious,  and  give  not  the  slightest  indica- 
tion, during  the  first  two  or  three  days  of  the  pa- 
tient's sufferings,  where  the  trouble  is  finally  to  settle. 
Obviously,  in  the  present  case  the  pain  was  ushering 
in  a  pneumonia.  I  recently  saw  a  woman  who  suffered 
for  two  days  from  quite  intense  pain  throughout  all 
the  tissues  of  the  thighs  and  legs.  We  could  find 
absolutely  no  cause  for  it,  though  the  presence 
of  an  accompanying  fever  and  leukocytosis  made  us  believe  that  some 
infective  agent  was  at  work.  The  joints,  the  nerves,  the  muscles  and 
subcutaneous  tissues,  the  arteries  and  \eins  were  searched  for  exidencc 
of  a  cause  for  tlie  ])ain,  Init  none  was  found.  On  the  third  day  an  acute 
dyscnterv  made  its  ap|)earance,  and  the  })ain  in  the  legs  quick!}-  dis- 
a])peared. 

Tn  \ie\v  of  these  and  similar  cases  we  must  always  1)ear  in  mind,  w lien 
examining  the  legs  for  a  cause  of  pain  referred  to  them,  that  a  utTieral 
unlocalized  infection  bearing  no  special  relation  to  tlie  leg  ma}  liaw 
in\aded  the  bodv.  Disease  of  the  brain  or  s])inal  cord  sliould  also  l)c 
remembered  as  among  the  Io)!<^-ra>!g('  ((luscs  for  leg  ])ains. 

Diagnosis. — Pneumonia. 


case  211. 


4CXD  DIFFERENTIAL  DIAGNOSIS 

Case  212 

A  homeopathic  confrere  called  me  in  consultation  October  31st  to 
see  a  curious  case  of  grip  with  pelvic  neuralgia  and  perhaps  malaria. 

The  patient  was  a  young  architect  of  twenty-seven,  always  pre- 
viously well  until  he  began,  October  ist,  to  have  what  he  called  "grip" 
— i.  e.,  a  fever  of  103.6°  F.,  accompanied  by  aching  in  his  head,  back, 
and  legs.  After  a  couple  of  days  the  temperature  fell  to  101°  F.,  and 
the  patient  had  what  was  called  a  right  facial  neuralgia.  From  October 
5th  to  October  12th  the  temperature  did  not  rise  above  100°  F.,  and 
the  patient  seems  to  be  convalescent,  though  complaining  somewhat 
of  piles.  He  then  went  off  for  a  week's  vacation,  but  on  his  return, 
October  19th,  said  that  he  had  been  poorly  while  he  was  away,  suffering 
a  great  deal  from  pain  in  the  testes,  which  was  especially  severe  every 
night  about  6  p.m.,  and  was  associated  either  with  a  rectal  tenesmus, 
a  urinary  frequency,  or  both.     The  pain  radiated  to  both  hips  and  groins. 

On  October  25th  the  temperature  was  again  101°  F.,  and  since  that 
time  it  has  risen  to  that  point  or  a  degree  higher  every  day.  On  the 
twenty-seventh,  quinin,  the  doctor  said,  seemed  to  stop  the  pelvic  neu- 
ralgia, but  for  the  last  two  days  he  has  been  eating  poorly,  and  at  1 1  p.m. 
to-day  his  temperature  was  103°  F.  and  the  pelvic  pains  so  great  as  to 
require  morphin.  The  urine  has  been  high  colored,  but  not  cloudy,  and 
shows  no  gross  sediment.     The  blood  has  not  been  examined. 

Physical  examination  of  the  chest  was  negative;  the  spleen  was  not 
enlarged,  and  the  blood  showed  no  malarial  organisms.  There  was 
no  evidence  of  an  influenzal  infection  of  the  upper  air-passages  or  else- 
where. The  urine  was  high  colored,  but  showed  no  other  important 
abnormality.  The  leukocytes  numbered  28,000,  83  per  cent,  of  which 
were  polynuclear. 

The  local  examination,  which  had  been  hitherto  neglected,  showed 
a  reddened,  tender,  and  resistant  area  close  to  the  rectum  on  the  left. 

Discussion. — -The  points  of  interest  in  this  case  are  the  slow  "set- 
tling" of  the  infection  at  the  point  where  it  was  finally  discovered, 
and  the  unwisdom  of  treating  symptoms  without  careful  physical 
examination.  In  view  of  the  local  conditions  one  could  hardly  doubt 
that  the  patient  was  suffering  from  an  abscess  near  the  rectum,  the 
wide  radiations  of  the  pain  being  due,  douljtless.  to  the  burrowings  of 
pus  which  should  have  been  liberated  long  before. 

Incision  allowed  the  escape  of  a  pint  and  a  half  of  pus.  The  abscess 
cavity  healed  up  in  the  course  of  three  weeks,  and  by  December  ist 
the  patient  was  back  at  work. 

Diagnosis. — Ischiorectal  abscess. 


CHAPTER  XIII 

FEVERS 

The  distinction  between  "long"  and  "short"  fevers — i.  e.,  those 
continued  for  two  weeks  or  more,  and  those  of  briefer  span — allows 
us  to  narrow  the  diagnostic  possibilities  of  the  "long"  group  practically 
to  three  alternatives:  tuberculosis,  sepsis,  typhoid. 

In  the  following  table  ^  I  have  classified  784  cases  in  which  a  fever 
lasted  two  weeks  or  more  without  touching  normal: 

Typhoid 586 

Sepsis 70 

Tuberculosis 54    710  (90  per  cent,) 

Meningitis 27 

"Influenza" 10 

Acute  "rheumatism" 9 

Leukemia 5 

Cancer 4 

Syphilis 2 

Trichiniasis 2 

Cirrhosis 2 

Gonorrhea 2 

"Scattering" 11      74  (10  per  cent,) 

784 

It  will  be  noted  that  most  of  the  10  per  cent.  0/  long  fevers  not  due  to 
typhoid,  tuberculosis  or  sepsis  are  due  to  diseases  easy  of  diagnosis 
because  of  their  local  or  distinctive  signs.  Thus  meningitis,  with  its 
evidences  of  cerebrospinal  irritation,  "rheumatism"  with  its  joint 
lesions,  leukemia  and  trichiniasis  with  their  blood  changes,  cancer 
with  the  easily  })alpable  tumors  which  febrile  cases  i)ractically  always 
show,  gonorrhea  and  cirrhosis  with  their  characteristic  local  manifesta- 
tions—all these  are,  or  should  be,  easily  recognized.  Obscure  long- 
continued  fevers,  then,  will  include  only  the  dominant  three,  plus  "in- 
fiucnza"  and  syphilis.  In  this  group  the  dominant  three  make  u[) 
pS  per  cent. 

instead  of  ''influenza"  we  should  write  "'unknown  infection"  against 
most  of  the  1.2  per  cent,  of  obscure  fe\ers  so  (Hagnosed  in  m\'  statis- 

*  R.  C.  ralx)t,  The  Three  T>)ng-r()ntinu('(i  Fevers  oi  New  Fnfjland.  Hosi'Ui  Miiiirai 
and  Surgical  Jnurnal,  August  2(),   i^o;. 


402 


DIFFERENTIAL   DIAGNOSIS 


tics,  for  bacteriologic  proof  of  influenza  was  rarely  obtained  in  this 
series.  I  do  not  doubt  that  long  as  well  as  short  fevers  may  be  pro- 
duced by  true  influenzal  infection,  but  I  believe  that  the  diagnosis  is 
rarely  well  founded  on  cultural  evidence. 

The  proportion  of  typhoid  in  the  figures  above  quoted  is  far  too 
high,  because  in  the  Massachusetts  General  Hospital,  whence  these 
figures  were  gathered,  the  typhoid  cases  of  a  large  area  are  aggregated. 
In  fact,  the  number  of  long  typhoid  fevers  is  generally  far  less  than 
the  number  of  long  tuberculosis  or  septic  fevers;  but  these  are  treated 
at  home  and  therefore  missed  in  hospital  statistics. 

The  manifold  manifestations  of  tuberculosis — in  the  spine,  the  hip. 
sacro-iliac,  and  other  joints,  in  the  lymph-nodes,  peritoneum,  meninges, 
and  genito-urinary  tract,  as  well  as  in  the  lungs  and  pleura — may  all  pro- 
duce long  as  well  as  short  periods  of  fever. 

Under  "sepsis"  I  mean  to  include  here  an  extensive  variety  of 
clinical  pictures,  such  as — (a)  vegetative  endocarditis  (also  called 
benign,  malignant,  ulcerative,  or  septic);  (b)  puerperal  fevers;  (c) 
deep-seated  abscesses  originating  in  the  appendix,  the  gall-bladder, 
the  genito-urinary  tract,  the  stomach,  and  duodenum;  (d)  empyema; 
(e)  wound  sepsis;  (J)  lymphangitis,  erysipelas,  and  phlegmonous  in- 
flammation. 

Yet  only  a  small  minority  either  of  tuberculous  or  of  septic  fevers 
are  obscure  in  origin  or  lead  us  to  any  diagnostic  puzzles.  The  osseous, 
lymphatic,  peritoneal,  and  meningeal  forms  of  the  disease  are  usually 
easy  of  recognition.  It  is  chiefly  the  pulmonary  and  renal  forms  of 
tuberculosis  that  are  latent  and  produce  obscure  fevers.  Among  the 
fevers  due  to  sepsis  also  the  great  majority  are  plain  enough.  It  is 
chiefly  in  the  cases  of  vegetative  endocarditis,  and  in  some  of  the  deep- 
seated  abscesses — especially  those  in  or  about  the  liver  and  kidney — 
that  local  symptoms  are  absent. 

Hence  we  may  say  that,  when  studying  obscure  fevers  of  long  dura- 
tion, we  should  search  especially  for: 

(a)  Pulmonary  and  renal  tuberculosis. 

(b)  Typhoid. 

(c)  Hepatic,  subphrenic,  renal,  or  perirenal  suppurations. 

(d)  Vegetative  endocarditis. 

Tlie.  lung,  the  liver,  the  kidney,  and  the  blood  are  especially  to  be 
suspected  and  examined.  Auscultation,  :v-ray  examination,  l)lood- 
counts,  cultures,  biologic  tests,  cystoscopy  and  a  carefully  taken  history 
will  help  us  most  in  difficult  cases. 


Causes  of  Long  Fevers 


^■■■^^^^^■^^^^^■^^i^^^^^H  1172 
2.  SEPSIS  ■■■■  140 

3.TUBERCUL0SISIHH  108> 

4.  MENINGITIS         WM  54 

5.  INFLUENZA  ■  20 


6.  INFECTIOUS 
ARTHRI 


)US| 
TIS  i 


U 


7.  LEUKEMIA             |  10 

8.  CANCER                  I  8 

9.  SYPHILIS                I  4 

10.  CIRRHOSIS            I  4 

11.  GONORRHEA        I  4 

12.  "SCATTERING"  ■  26 

•  In   st.uistics  of  liospitals   for  chronic  diseases  this  ficure  is  often  much   larger  pru- 
porlionally. 


lo:; 


Causes  of  Short  Fevers 

(Omitting   those   listed   under   "  Long    Fevers "    and    excluding    the 
exanthemata  and  diphtheria.) 


1.  "COMMON  COLDS," 
Including  : 

(a)  ACUTE  ■> 
BRONCHITISJ 

(b)  ACUTE  1 

tonsillitis/ 


(c)  ACUTE 
PHARYNGITIS 

(d)  ACUTE 


} 


I)  ACUTE  -1 

"INFLUENZA"  i 

2.  ACUTE  APPENDICITIS 

3.  ACUTE  ARTHRITIS 

4.  SALPINGITIS 

5.  PNEUMONIA 

6.  LYMPHANGITIS 

7.  SINUSITIS 

8.  ERYSIPELAS 

9.  POLIOMYELITIS 


4164 

T620 

1405 

751 

388 
1504 
<016 
871 
803 
365 
259 
241 
227 


404 


FEVERS  ^O^ 

SHORT  FEVERS 

Excluding  the  exanthemata  and  the  milder  types  of  the  infections 
just  mentioned,  we  may  say,  I  think,  that  the  majority  of  short  fevers 
are  of  unknown  origin.  The  habit  of  attributing  such  fevers  to  "  com- 
mon colds,"  to  "grip,"  "influenza,"  "febricula,"  "auto-intoxication," 
"rheumatism,"  constipation,  etc.,  is  a  pernicious  way  of  concealing 
our  ignorance  not  only  from  our  patients,  but  from  ourselves. 

The  temperature-pulse  ratio  has  never  seemed  to  me  of  much  prac- 
tical value  in  diagnosis.  It  may  confirm  a  diagnosis  established  mainly 
in  other  ways,  but  in  my  experience  it  is  as  apt  to  lead  us  wrong  as 
right.  In  typhoid  the  pulse  may  be  relatively  slower  than  in  fe\'er  of 
similar  degree  due  to  pneumonia,  sepsis  or  tuberculosis,  but  there  are 
many  exceptions  to  this  rule. 

The  rapidity  of  respiration  is  also  a  very  unreliable  guide.  Many 
non -respiratory  infections  {e.  g.,  typhoid,  erysipelas,  liver  abscess) 
may  notably  quicken  the  respiration,  while  the  sudden  fall  of  respira- 
tion at  the  crisis  in  pneumonia,  when  the  lung  signs  remain  quite  un- 
changed, inclines  us  to  believe  that  even  in  pneumonia  the  polypnea 
is  due  to  the  general  rather  than  to  the  local  pulmonary  condition. 

NON-INFECTIOUS  FEVERS 

(a)  Brain  injuries  and  diseases  of  any  kind  may  produce  iever  of 
various  types.  Thus  cerebral  hemorrhage,  tumor,  and  acute  delirium 
due  to  alcohol  or  other  causes,  often  raise  the  temperature  consideral)ly. 

Other  important  causes  are: 

(b)  Malignant  tumors  (such  as  cancer  of  the  hvcr,  Hodgkin's  disease), 
especially  wlien  extensive  and  of  rapid  growtli. 

(e)   Leukemia  and  all  types  of  severe  anemia. 

(d)  Poisoning  l)y  belladonna  and  ilhiminating  gas. 

{e)  Uremia,  eelampsia,  hepatic  toxemia,  gout,  and  hyperthyroidism 
(Graves'  disease). 

if)    Sunstroke. 

Whether  ])ure  "nervousness"  or  hysteric  states  of  one  or  another 
type  can  produce  fever  is  a  (juestion  which  frequently  arises. 

Pyrexia  not  exceeding  ioo°  F.  and  of  short  duration  certainly  accom- 
panies many  sucli  psychoses.  Temperatures  taken  when  a  ] salient 
first  enters  a  hospital  often  register  102°,  103°,  or  104°  F.,  but  are 
followed  by  normal  records  within  tweh"c  to  twentv-four  hours.  Ex- 
haustion and  alarm  (loul)tless  contril)ute  to  ]ir(Hluce  these  temporary 
abnormalities.  Aside  from  the  two  ty])es  of  fcxer  just  mentioned,  I 
haw  no  experience  of  pvrexias  due  to  ])sycliic  causes. 


4o6  DIFFERENTIAL  DIAGNOSIS 


Case  213 


A  fourteen-months-old  girl  baby  was  seen  December  23,  1902.  She 
was  born  in  Cuba,  had  malaria  before  she  left  the  island,  and  since  she 
came  to  live  in  Cambridge,  Mass.,  had,  during  the  summer  just  past,  a 
large  number  of  mosquito-bites.  November  i6th  the  baby  began  to 
vomit,  lost  appetite  and  soon  became  weak  and  listless.  She  was  fed 
on  Eskay's  food  and  milk.  From  that  time  on  she  ran  a  continuous 
fever,  ranging  from  100.6°  to  104°  F.,  with  long  excursions  almost  every 
day.  She  was  fretful  and  listless,  dozing  most  of  the  time,  rolling  her 
head  back  and  forth  upon  the  pillow,  running  her  tongue  repeatedly  over 
the  region  of  the  expected  incisor  teeth,  but  exhibiting  no  more  definite 
localizing  symptoms. 

The  symptoms  were  ascribed  to  teething,  but  the  child  grew  steadil}' 
worse,  and  by  December  2d  voluntary  motion  of  the  extremities  had 
almost  altogether  ceased.  Repeated  physical  examinations  elicited 
nothing  either  in  the  legs  or  elsewhere.  December  3d  the  child  seemed 
to  be  markedly  "anemic,"  and  it  was  difficult  to  obtain  blood  from  the 
toe.  Nevertheless,  the  hemoglobin  was  80  per  cent.  The  Widal  reac- 
tion was  negative;  the  white  cells,  6500.  lodophilia  was  very  marked. 
The  child  was  seen  by  Dr.  C.  P.  Putnam  daily  for  a  week,  but  no  diag- 
nosis was  made. 

December  6th  a  squint  was  noticed.  This  disappeared  within 
twenty-four  hours  and  has  not  recurred  since.  December  23d,  the  fe\'er 
continuing  unabated,  while  the  child  grew  constantly  thinner,  I  saw  her 
in  consultation,  but  could  make  no  diagnosis.  The  blood  showed  at 
this  time: 

Red  cells,  4,892,000;  white  cells,  39,000;  hemoglobin,  80  per  cent.; 
iodophilia,  very  marked;  among  the  leukocytes,  93.6  per  cent,  were  poly- 
nuclear. 

A  week  later  Dr.  T.  M.  Rotch  saw  the  baby,  noticed  a  slight  "rosary," 
made  a  diagnosis  of  rickets,  and  directed  the  treatment  accordingly. 
Nevertheless  the  child  continued  to  go  down-hill. 

Discussion. — As  in  the  case  previously  mentioned,  there  was  no 
culture  made  from  the  urine,  and  the  possibility  of  urinary  infection 
was  not,  so  far  as  I  know,  considered.  One  heard  nothing  of  such 
infections  in  1902.     The  ears  were  examined,  with  negative  result. 

As  the  child  had  Ijcen  healthy  at  l^irth,  had  been  properly  fed  during 
most  of  its  life,  and  showed  no  more  signs  of  rickets  than  a  large  propor- 
tion of  healthy  children,  there  seemed  to  me  no  good  reason  to  attribute 
its  serious  and  progressive  symptoms  to  that  disease. 


Fit;;.  78. — Condition  of  the  spleen  and  liver  in  Case  214. 


FEVERS 


407 


Outcome. — January  23d  the  child  died.  Autopsy  by  Dr.  W.  T. 
Councilman  showed  in  the  kidneys  numerous  foci  of  hemorrhage 
between  the  tubules;  also  here  and  there  infiltrations  of  leukocytes,  so 
extensive  as  to  constitute  small  abscesses  with  destruction  of  the  tubules 
and  epithehum.  Organisms  of  the  colon  group  were  found  in  these 
lesions. 

At  the  time  when  this  baby's  illness  occurred  the  frequency  and  import- 
ance of  the  urinary  infections  of  girl  babies  was  not  recognized.  Natur- 
ally, therefore,  no  one  thought  of  this  diagnosis  during  the  life  of  the  child, 
though  in  all  probability  this  life  might  have  been  saved  had  the  urinary 
tract  been  investigated  earlier. 

Diagnosis. — Renal  infection  (bacillus  coli). 

Case  214 

A  real-estate  broker  of  thirty-nine  was  seen  June  19,  1909.  He  had 
"  typhoid  "  when  he  was  six,  and  again  when  he  was  twenty-one.  For 
the  ten  years  succeeding  this  attack  he  had  gall-stone  colic  in  frequent 
paroxysms,  which  were  finally  cured  by  an  osteopath  in  1900,  He  had 
no  fever  at  that  time.    His  wife  died  in  1900.    He  married  again  in  1908. 

February  24,  1909,  he  went  to  Alabama  feeling  perfectly  well.  About 
six  weeks  ago  he  lost  his  appetite  and  began  to  have  a  headache,  with 
much  pulsation  in  his  head.  Soon  after  he  noticed  that  climbing  a  slight 
hill  exhausted  him  completely.  For  the  past  thirty-three  days  he  had 
been  aware  that  he  had  fever,  ranging  between  99°  and  103°  F.,  and 
usually  reaching  the  lower  figure  once  or  more  in  every  forty-eight  hours. 
With  this  fever  he  had  repeated  chills  and  lost  fifteen  pounds. 

He  returned  from  the  south  a  month  ago,  and  has  been  in  bed  for 
ten  days,  troubled  a  good  deal  with  gas  in  his  bowels,  with  occasional  belly 
pain  and  much  weakness.  Some  weeks  ago  a  homeopathic  ])athologist 
found  a  malarial  parasite  in  his  blood,  and  since  then  he  has  received  at 
least  20  grains  of  quinin  a  day.  Ne\'erthelcss,  he  has  continued  to  lia\-e 
fe\er  and  has  grown  steadily  paler,  thinner  and  weaker. 

On  physical  examination  he  shows  a  yellowish  pallor,  hemoglobin 
being  55  per  cent.  The  conjunctivae  are  not  discolored;  the  urine  shows 
no  bile-j)igment.  The  chest  and  extremities  are  negati\"e,  the  abdomen 
as  per  diagram  (Fig.  78).  The  edge  of  the  spleen  and  li\er  are  both 
very  sharp  and  hard;  the  surface  of  the  li\er  seems  to  be  somewhat 
irregular.     There  is  no  ascites. 

Discussion. — As  will  be  at  once  surmised  from  the  treatment  referred 
to  above,  malaria  was  the  diagnosis  u]i  to  June  icjth.  The  (.hills,  the 
anemia,  the  large,  hard  spleen  and  the  report  of  nialarial  parasites  in  the 


4o8 


DIFFERENTIAL  DIAGNOSIS 


blood  had  led  xery  naturally  to  this  diagnosis.  Yet  in  my  opinion  malaria 
could  be  absolutely  excluded,  owing  to  the  fact  that  the  fever,  though 
approaching  the  tertian  type  more  nearly  than  any  other,  did  not  yield 
appreciably  to  large  doses  of  quinin,  which  were  obviously  absorbed, 
as  the  patient's  ears  had  been  ringing  steadily  for  weeks.  My  examina- 
tion of  the  blood  revealed  no  trace  of  malarial  parasites.  The  red  cells 
numbered  3,120,000;  the  leukocytes,  4800,  the  different  varieties  being 
present  in  approximately  normal  percentages. 

By  the  blood  examination  just  reported  leukemia  could  be  excluded. 
I  have  seen  a  very  similar  clinical  picture  produced  by  myeloid  leukemia, 
but  the  blood  was  in  that  case  very  distinctive  and  the  chills  less  num- 
erous. 

As  the  patient  has  a  history  of  gall-stone  colic  and  has  now  an  irregu- 
lar fever  with  chills  and  enlargement  of  liver  and  spleen,  it  is  natural  to 
consider  for  a  moment  the  possibility  that  he  may  now  be  suffering  from 
gall-stone  fever.  The  condition  of  the  abdomen  and  the  course  of  the 
temperature  are  consistent  with  that  diagnosis,  although  the  spleen  is 
unusually  large;  but  gall-stone  fever  is  almost  always  accompanied  either 
by  attacks  of  pain  or  1)y  more  or  less  transient  yellowing  of  the  conjunctiva 
during  some  part  of  the  attack. 

The  irregular  surface  of  the  liver,  if  it  be  taken  as  an  established 
fact,  is  of  great  diagnostic  importance,  as  there  are  but  two  common 
diseases  which  produce  hepatic  enlargement  with  irregularities  of  surface 
palpable  through  the  abdominal  wall,  viz.,  cancer  of  the  liver  and  syphilis 
of  the  liver.  Both  of  these  diseases  may  be  associated  with  fever,  though 
this  is  more  common  in  syphilis.  The  age  of  the  patient,  the  freedom 
from  marked  gastric  symptoms,  and  the  size  of  the  spleen  point  distinctly 
toward  syphilis  rather  than  cancer. 

As  soon  as  I  asked  the  patient  the  direct  question,  he  admitted  that  he 
had  had  syphilis  seven  years  pre\iously,  and  been  treated  for  it  by  a  well- 
known  specialist  whose  diagnosis  I  knew  to  be  irreproachable.  The 
patient  had  concealed  this  portion  of  his  history  even  from  his  attending 
physician,  who  had  not  happened  to  ask  him  the  direct  question. 

Outcome. — The  patient  was  at  once  put  on  intramuscular  injections 
of  mercury  with  15  grains  of  potassium  iodid  after  each  meal.  By  June 
28th  his  fever  was  abating  and  general  improvement  quite  noticeable. 

He  afterward  made  a  complete  recovery. 

Diagnosis.— Syphilis 


Fig.  79. — Physical  signs  in  Case  215.     No  dulness;    no  bacilli  in  sputa;    died  of  phthisis 

in  two  weeks. 


Fig.  80.— Physical 


in  a  case  of  unexplained  fe\er.     Practicalh'  no  cough. 


FEVERS  ^^ 


Case  215 


I  was  called  October  24,  1905,  to  see  a  young  man  of  twenty-four — a 
steam-gage  fitter.     I  reproduce  the  history  as  it  was  given  to  me. 

He  had  complained  of  a  week's  increasing  dyspnea  and  great  lassi- 
tude. The  attending  physician,  who  saw  him  at  the  beginning  of  this 
illness,  had  kept  a  temperature  chart  which  show-ed  that  there  had 
been  fever  each  day,  rising  to  101°  or  102°  F.  at  night.  The  pulse 
range  was  from  100  to  112.  The  respiration  rate  showed  a  steady 
rise — 28  for  four  days,  30  for  the  succeeding  two  days,  and  36  for  the 
past  twenty-four  hours.  There  was  much  sweating  with  the  fever, 
but  no  pain  and  no  other  symptom  except  a  slight,  dry,  hacking  cough, 
which  was  not  complained  of  and  produced  nothing  until  the  day 
previous,  when  a  single  small  mucopurulent  mass  was  expectorated. 
This  was  examined  at  the  Board  of  Health  laboratory  and  found  to  be 
negative.  The  urine — 1025 — contained  a  trace  of  albumin,  a  few 
fine  and  coarse  granular  casts,  and  a  positive  diazo-reaction. 

The  blood  showed  no  Widal  reaction.  There  was  no  wound  or  other 
known  source  for  sepsis;  no  history  of  syphilis;  no  recent  gonorrhea. 
The  chest  and  abdomen  had  been  examined  with  negative  results. 

What  possibilities  should  be  here  investigated? 

1.  The  past  history  should  be  scrutinized. 

2.  The  physical  examination  should  be  repeated  with  special  reference 
to  the  presence  of — 

(a)  Central  pneumonia;  (b)  endocarditis  and  pericarditis;  (c) 
typhoid;  (d)  miliary  or  generalized  tuberculosis. 

Further  investigation  of  his  past  history  showed  that  he  had  always 
been  well,  although  in  the  previous  August  he  had  had  some  s\\ollcn 
glands  in  the  side  of  his  neck,  which  persisted  for  three  weeks  and 
were  accompanied  by  night-sweats.  After  that  he  felt  very  well  and 
went  to  work  again. 

Physical  examination  showed  the  signs  indicated  in  Figs.  79 
and  80.  The  heart  and  pericardium  showed  nothing  abnormal. 
The  temperature  chart  [showing  a  normal  or  subnormal  temj)erature  eacli 
morning]  was  ])ractically  sufficient,  considering  the  previous  course  of 
the  illness,  to  exclude  typhoid  and  central  ])neumonia.  The  leukocyte 
count,  which  was  normal,  added  to  the  e\idence  against  pneumonia. 

The  boy  did  not  cough  at  all  during  my  visit,  l)ut  the  character  of 
the  signs,  when  taken  in  connection  with  the  fever  and  other  sym])toms, 
seems  to  me  to  point  strongly  toward  ])ulmonary  tuberculosis,  of  which 
disease  he  died  two  weeks  later. 


4IO 


DIFFERENTIAL   DIAGNOSIS 


The  attending  physician  was  much  surprised  and  rather  skeptical 
at  my  diagnosis,  "for,"  as  he  said,  "the  boy  has  practically  no  cough, 
almost  no  sputa,  and  what  he  does  raise  has  been  examined  and  found 
negative."  It  cannot  be  too  strongly  insisted,  in  view  of  this  and  many 
other  similar  cases,  that  a  negative  sputum  examination,  unless  it  has 
been  many  times  repeated,  should  never  be  considered  as  evidence 
against  pulmonary  tuberculosis.  Even  then  it  is  by  no  means  conclusive, 
as  bacilli  may  not  appear  for  many  weeks  or  even  months  after  the  onset 
of  the  disease  in  the  lung. 

Diagnosis. — Pulmonary  tuberculosis. 

Case  216 

On  January  i8,  1897,  soon  after  the  discovery  of  Widal's  reaction 
in  typhoid  fever,  I  was  asked  to  examine  the  blood  of  a  febrile  case  in 
which  that  diagnosis  seemed  fairly  certain.     Some  confirmation,  how- 


"^/r'^j.  11 1  1  1  1  1 

J  M   i    l_2   i -2  Ji  U  Ji  Mi  di  Jl  A  a.  Ik -^  i-£  i^ 

107-  —  — ^!Li!l!?l!!^L!l! 

■  ■•i>>.>.>aiii>iiiiiiiiiiliiiii>«>iiljj 

lot 

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10 

Fig.  81. — Chart  of  case  216. 


ever,  was  desired.  Four  weeks  previously  the  patient  had  had  a  mastoid 
operation  following  an  attack  of  otitis  media.  All  had  gone  well,  and 
the  wound  was  now  almost  healed ;  only  a  small  area  of  healthy  granu- 
lations remaining  in  the  mastoid  region.  Nevertheless,  soon  after  the 
operation  the  patient  had  begun  to  ha\-e  fc\-er,  the  course  of  which  is 
shown  in  the  accompanying  chart  (Fig.  80). 


FEVERS 


411 


Throughout  its  course  he  had  complained  of  nothing  except  such 
discomforts  as  could  be  reasonably  attributed  to  the  fever  itself.  He 
had  had  no  headaches,  no  tenderness  at  or  near  his  wound,  no  symptom 
that  would  serve  to  localize  any  cause  for  the  fever. 

At  the  time  of  my  examination  a  group  of  typical  rose  spots  were 
scattered  over  the  abdomen.  Each  spot  was  about  2  mm.  in  diameter, 
and  disappeared  wholly  on  pressure.  The  spleen  was  not  palpable, 
and  visceral  examination  was  otherwise  negative,  with  the  exception  of  a 
few  scattered  rales  at  the  base  of  each  lung. 

The  blood  examination  showed  leukocytes,  23,000,  88  per  cent,  of 
which  were  polynuclear.  The  Widal  reaction  was  entirely  negative, 
even  in  dilutions  of  1:10. 

Discussion. — I  reported  to  the  surgeon  in  charge  of  the  case  that  it 
w^as  not  one  of  typhoid  fever,  and  that  I  belie\ed  some  type  of  wound 
infection  must  be  present.  At  that  time  I  did  not  know  of  the  common- 
ness of  infectious  thrombosis  of  the  lateral  sinus  and  jugular  vein,  since 
so  thoroughly  studied  by  Libman  '  in  its  relations  to  bacteriemia. 
Doubtless  micro-organisms  might  have  been  culti\"ated  from  the  cir- 
culating blood  had  I  known  at  that  time  the  importance  of  the  test. 

A  great  skepticism  of  my  results  was  expressed  at  the  time.  The 
chart  was  so  typically  that  of  typhoid,  the  rose-spots  so  diagrammatic, 
the  patient  so  completely  free  from  any  local  symptoms  or  complaints, 
that  it  seemed  absurd  to  exclude  ty})hoid  on  the  e\"idence  of  so  academic 
a  laboratory  test  as  blood  examination.  This  was  before  we  had  been 
shown  by  thousands  and  tens  of  thousands  of  blood-counts  that  un- 
complicated ty])hoid  never  produces  such  a  leukocytosis  as  that  here 
recorded,  and  that  the  absence  of  a  Widal  reaction  after  four  weeks  of 
fever  is  strong  evidence  against  the  existence  of  typhoid. 

Outcome. — The  patient  died  January  21st;  autoj)sy  showed  a  septic 
thrombosis  of  the  lateral  sinus  and  jugular  vein. 

Diagnosis. — Se})tic  thrombosis  of  the  lateral  sinus  and  jugular  vein. 

Case  217 

A  j)hysician  of  thirty-nine  was  seen  Xo\'ember  30,  1905.  Six  years 
])reviously  he  had  had  the  grip,  followed  by  weakness,  emaciation  and 
night-sweats.  Pulmonary  tuberculosis  was  suspected,  but  not  pro\"e(l. 
Tie  went  south  for  two  months  and  recovered  entirely,  and  has  sinet-  tlien 
worked  very  hard,  "mostly,"  he  savs,  "on  his  nerve." 

August  17,   T905,  a  hair-follirk'  on  his  linger  got  infected.     It  was 

'The  Tniix)rlan(  (•  of  Hlood  Culture  in  the  Studv  of  Iiifcrlions  of  f^tiiir  (>rin;in,  by 
K.  Lihman  and  II.  I.,  (■(•llcr,  Trans.  As.soi .  .Vnit-r.  rh\si(ians,  looo.  p.  .;'m. 


412  DIFFERENTIAL  DIAGNOSIS 

opened  and  cureted  on  the  nineteenth  under  cocain.  He  felt  much  ex- 
hilarated thereafter,  and  made  his  medical  calls  as  usual  throughout  the 
rest  of  the  day.  In  the  evening  he  collapsed,  and  had  a  very  severe  pain 
in  the  right  intercostal  region,  accompanied  by  high  fever  not  relieved  by 
poulticing,  and  only  modified  by  |  grain  morphin.  Next  day  the  signs 
of  pleurisy  were  found,  and  two  days  later  an  area  the  size  of  an  orange 
appeared  near  the  angle  of  the  right  scapula.  Over  this  the  breathing 
was  bronchovesicular,  with  dulness  and  crackling  rales.  These  signs 
lasted  without  much  change  for  four  weeks,  and  were  not  wholly  gone  for 
two  weeks  more.     An  irregular  fever  persisted  throughout. 

October  6th,  though  still  weak,  and  despite  the  presence  of  high- 
pitched  respiration  over  the  area  described  above,  he  felt  well  enough 
to  be  moved  to  the  White  Mountains,  where  he  rapidly  improved,  ate 
well  and  slept  well,  took  four-mile  walks,  and  had  no  cough  to  speak  of. 
He  had  several  bad  headaches,  but  otherwise  felt  well  and  returned  to 
work  October  26th.  At  this  time  his  lungs  were  examined  and  found 
normal;  his  sputa  contained  no  bacilli  and  no  elastic  fibers.  The  day 
after  his  return  he  got  ov'ertired  and  again  collapsed,  i.  e.,  could  not  talk, 
eat,  or  sit  up,  had  a  bad  headache,  and  was  awake  all  night. 

Next  day  he  felt  better,  and  the  day  after  felt  "like  a  fighting  cock." 
During  the  next  ten  days  he  did  his  medical  work  as  usual,  although  he 
felt  somew^hat  poorly  every  second  day.  November  3d  he  did  a  very 
hard  day's  work,  and  at  the  end  of  it  felt  chilly  and  languid.  His  tem- 
perature was  found  to  be  102°  F.  From  November  3d  to  November 
30th — the  day  on  which  I  saw  him — he  had  an  irregular  fever,  accom- 
panied by  headaches.  All  his  symptoms  tended  to  be  worse  every  second 
day. 

Two  of  his  colleagues  saw  him  in  consultation  November  loth, 
the  diagnoses  considered  being  grip,  malaria,  and  simple  nervousness. 
The  spleen  was  felt,  and  accordingly  quinin,  24  grains  daily,  and  Fowler's 
solution,  5  minims  three  times  a  day,  were  administered.  The  quinin 
hammered  the  temperature  down,  but  it  rose  again  as  soon  as  the  drug 
was  stopped.  The  blood  was  twice  examined  at  this  time,  and  found 
to  be  normal ;  no  anemia,  no  leukocytosis,  no  Widal  reaction.  The  urine 
was  also  normal  (November  13th). 

By  this  time  the  doctor — always  of  a  very  high-strung  nervous  tem- 
perament— had  gotten  so  worked  up  about  himself  that  he  was  again  sent 
to  the  country,  but  while  there  still  had  fever,  ranging  from  100°  F.  in 
the  morning  to  101.4°  F.  in  the  evening,  despite  the  administration  of 
quinin,  24  grains  a  day.  During  the  last  two  weeks  he  has  had  ten  days 
of  pain  over  the  lower  left  back,  in  the  region  of  the  diaphragmatic 


Fig.  82.— rhysical  signs  simulating  juilmonary  tuberculosis  in  a  case  ot  sepsis  with  pros- 
tatic and  ])erine])hric  abscess.     Complete  and  lasting  recovery  followed. 


FEVERS 


413 


attachment.  Throughout  the  last  ten  days  of  his  fever  he  has  also  had 
pain  in  urination,  and  for  the  past  few  days  some  distress  in  the  rectum 
and  perineum. 

On  the  twenty-ninth  of  November  he  returned  to  his  home  feeling 
pretty  poorly  and  eating  very  little. 

Examination  November  30th  showed  temperature  100°  F.,  no  emacia- 
tion, abdomen  negative,  spleen  not  felt,  lungs  as  per  diagram  (Fig.  82). 

Discussion. — Typhoid  and  malaria,  it  seemed  to  me,  could  be  easily 
ruled  out.  I  could  find  no  evidence  of  any  form  or  focus  of  sepsis. 
Accordingly,  I  made  the  diagnosis  of  pulmonary  tuberculosis.  December 
ist  the  prostatic  symptoms  became  more  marked;  tenderness  and  fluc- 
tuation appeared  in  the  perineum  and  a  large  prostatic  abscess  was 
evacuated. 

December  loth,  tenderness  and  swelling  appeared  in  the  region  of  the 
left  twelfth  rib.  Incision  liberated  a  large  amount  of  pus  from  the  region 
of  the  kidney,  which  was  not  felt  or  seen.  The  patient  made  an  une\ent- 
ful  recovery,  and  has  been  well  ever  since  (October,  1910). 

I  made  two  chief  mistakes  in  this  case:  ftrst,  in  forcing  myself  to 
make  some  diagnosis,  even  an  improbable  one,  because  e\ery thing  else 
seemed  more  improbable.  The  proper  course  would  have  been  to  wait 
until  something  more  distinctive  appeared. 

My  second  blunder  was  in  paying  so  little  attention  to  symptoms  on 
the  part  of  the  bladder  and  rectum,  which,  though  very  trilling  at  the  time 
when  I  saw  the  patient,  were  enough  to  suggest  the  presence  of  a  septic 
focus  which  became  evident  within  twenty-four  hours. 

Diagnosis. — Perirectal  abscess;  perinephric  abscess. 

Case  218 

A  married  woman  of  thirty-two  consulted  me  in  OctolxT,  190S,  ac- 
companied by  her  ])hysician,  who  was  an  intimate  friend  of  the  family. 
The  diagnosis  was  s])lcnic  anemia,  and  the  ])r()blem  ])rcscntcd  to  me  for 
consideration  was  whether  S])lenectomy  should  be  done. 

'J"he  })atient's  coni])laints  were  of  general  weakness,  languor,  and  a 
dragging  sensation  in  the  left  axillary  region.  A  slight  continued  fe\er 
was  found  to  be  j)resent.  The  spleen  reached  almost  to  the  na\el.  and 
ap])eared  to  be  unusually  immoljilc,  ])erha])S  owing  to  the  pri'Sfncc  of 
adhesions.  \'isceral  examination  was  otherwise  ncgati\e.  Tiic  l)l(>od 
showi'd  3,500,00x3  red  cells,  Sooo  leukocytes.  45  per  cent,  of  henioulobin. 
The  differential  count  showed  nothing  worthy  of  note.  Tiie  red  cells 
showed  in  the  stained  smear  a  marked  achromia  with  slight  \  a  rial  ions 
in  size.     Xo  nucleated  red  cells  were  seen. 


,j^  DIFFERENTIAL   DIAGNOSIS 

The  patient  was  advised  to  enter  the  hospital  for  more  careful  study, 
and  probably  for  an  eventual  splenectomy.  She  delayed,  however, 
nearly  three  months  before  accepting  this  suggestion.  Meantime  there 
had  been  a  considerable  accumulation  of  fluid  in  the  abdominal  cavity, 
and  tapping  had  already  been  required  about  two  weeks  before  her 
entrance  to  the  hospital. 

A  reexamination  of  the  patient  at  this  time  showed,  except  for  the 
ascites,  no  especial  change  as  compared  with  the  conditions  previously 
found,  although  the  anemia  had  slightly  increased.  The  temperature 
continued  slightly  elevated,  the  pulse,  respiration,  and  urine  normal. 
Blood-pressure,  125.  Although  I  was  somewhat  apprehensive  that  he- 
patic changes  might  have  progressed  so  far  as  to  prevent  the  splenec- 
tomv  from  relie^•ing  her  symptoms,  it  seemed  as  if  she  were  going  on  from 
bad  to  worse  in  spite  of  all  that  good  hygiene  and  the  administration  of 
iron  and  arsenic  could  do;  hence  it  seemed  best  to  go  on  with  the  splen- 
ectomy, perhaps  preceding  it  by  a  direct  transfusion  of  blood. 

At  this  juncture  Dr.  Wilder  Tileston  saw  the  patient  at  my  request, 
and,  in  conversation  with  him,  the  patient  mentioned  that  she  had  been 
troubled  for  a  long  time  with  catarrh  and  cold  in  her  head.  "It  had 
been  there  so  long,"  she  said,  "that  I  am  getting  quite  used  to  it;  but 
a  little  while  ago,  as  I  was  blowing  my  nose,  something  came  away,  and 
I  noticed  that  there  was  a  passage  from  one  nostril  to  the  other,  inside." 

Discussion. — Following  up  this  hint.  Dr.  Tileston  learned  that  she 
had  had  "some  sort  of  skin  disease"  in  her  scalp,  as  a  result  of  which 
there  were  still  marked  unevennesses  over  the  cranial  vault,  though  the 
skin  was  wholly  normal. 

No  other  evidences  of  her  previous  syphilis  were  demonstrable  either 
in  the  history  or  in  the  physical  examination,  but  the  facts  seemed  to 
me  to  warrant  an  immediate  abandonment  of  the  plan  for  splenectomy 
and  a  thorough  trial  of  antisy])hilitic  treatment,  which  she  had  never 
had.  As  a  result  of  this  she  gradually  returned  to  perfect  health,  the 
spleen  diminished  to  one-quarter  its  former  size,  the  anemia  and  ascites 
disappeared,  and  the  patient  was  enabled  to  take  up  her  usual  mode  of 
life. 

This  was  a  very  narrow  escape  from  a  serious  mistake.  There  was 
nothing  in  the  history,  as  given  to  me,  to  suggest  syphilis.  Doubtless 
I  was  misled  ])artly  by  the  obvious  innocence  of  the  woman,  partly  by 
the  fact  that  her  physician,  who  was  intimate  both  with  her  and  with 
her  husband,  had  clearly  no  idea  that  the  liusband  had  been  infected 
previous  to  marriage.  Nevertheless,  I  ought  to  have  considered  syphilis 
merely  from  the  association  of  the  enlarged  spleen  and  ascites  with  an 


Pig,  83._chest  signs  obtained  on  physical  examination  of  Case  219. 


Fig.  S4.  — Tencil  sketch  from  an  .v-ray  jilate  of  Case  2ig. 


FEVERS 


415 


anemia  of  unknown  cause,  for  in  that  text-book  which  we  should  all 
know  by  heart  I  find  the  following,  under  Syphilis  of  the  Liver: 

"  In  a  second  group  of  cases  the  patient  is  anemic,  the  liver  is  enlarged, 
perhaps  irregular,  and  the  spleen  also  is  enlarged.  Dropsical  symptoms 
may  supervene."  (Osier's  Practice  of  Medicine,  seventh  edition,  p. 
276.) 

Diagnosis. — Syphilis. 

Case  219 

A  boarding-school  boy  of  sixteen  was  seen  December  12,  1907. 
He  had  had  a  "regular  cold"  with  a  little  fever  which  seemed  to  be 
ended  three  days  ago,  but  next  day  the  temperature  rose  again  to 
102°  F.  Yesterday  morning  crackles  were  heard  for  the  first  time  at  the 
right  base.  Last  night  at  midnight  he  vomited  and  complained  of  pain 
in  the  right  axilla  on  coughing.  When  examined  at  7  p.  m.  his  tempera- 
ture was  102°  F.,  his  pulse  90  and  dicrotic.  Except  for  slight  disten- 
tion of  the  belly,  the  abdomen  and  extremities  showed  nothing  abnormal, 
likewise  the  left  lung.  Examination  of  the  base  of  the  right  lung  behind 
showed  in  some  positions  nothing  but  enfeebled  vesicular  respiration, 
but  when  lying  on  the  right  side  there  were  crackles,  increased  whisper, 
and  a  small  patch  of  feeble  bronchial  breathing  near  the  angle  of  the 
scapula. 

Although  these  signs  were  not  very  distinctive,  their  association 
with  a  typical  rusty  sputum  and  a  high  leukocyte  count  seemed  to  me 
to  justify  a  diagnosis  of  lobar  pneumonia.  On  the  nineteenth,  as  the 
temperature  suggested  an  empyema,  a  needle  was  put  in  near  the  angle 
of  the  scapula,  but  only  an  ounce  of  bloody  serum  was  obtained.  On 
the  twenty-fourth  he  was  tapped  again,  this  time  in  the  axillary  line, 
and  an  .v-ray  was  taken  of  the  chest,  which  showed  nothing  abnormal. 

January  3d  the  temperature  was  normal,  the  boy  hungry  and  sleep- 
ing well,  but  the  chest  signs  were  still  far  from  normal.  On  January 
6th  the  temperature  rose  again,  and  though  the  boy  was  still  eating, 
sleeping,  and  feeling  finely,  the  signs  were  as  in  the  accompanying 
diagram  (Fig.  83).  The  front  of  the  chest  and  the  axilla  showed 
notliing  of  im]K)rtancc.  The  boy's  temperature  was  101.6°  F.  in  the 
morning,  99.4°  F.  in  the  afternoon.  January  7th  it  was  102.2°  F.  in 
the  morning,  100°  F.  in  the  afternoon.  Between  this  date  and  the 
twenty-second  of  January  two  other  unsuccessful  taps  were  made. 
The  boy  continued  in  excellent  condition  despite  his  daily  fe\er.  The 
sj)utum  was  repeatedly  examined,  with  negative  rcsuhs. 

At  this  time  he  was  moved   to  New  York  city  and  put  in  charge  of 


4i6 


DIFFERENTIAL   DIAGNOSIS 


Dr.  Evan  Evans.  A  second  jc-ray  made  at  this  time  showed  the  appear- 
ances sketched  in  Fig.  84.  January  2  2d  pus  was  finally  found  under 
the  scapula  by  a  puncture  made  through  the  axilla.  The  boy  made  an 
excellent  recovery. 

Diagnosis. — Interlobar  postpneumonic  empyema. 

Case  220 

A  girl  of  six  entered  the  hospital  November  18,  1907.  She  has 
always  been  weak,  and  often  complained  of  her  ears.  She  has  had 
measles,  chicken-pox,  and  whooping-cough.  Three  days  before  en- 
trance she  fell  and  hurt  her  head.  That  night  she  was  feverish  and 
complained  of  headache.  The  next  day,  her  mother  said,  she  "never 
opened  her  eyes."  She  has  vomited  watery  material  several  times, 
and  continued  to  complain  of  pain  in  her  head,  also  in  the  abdomen. 
She  has  been  somewhat  constipated.      She  has  been  in  bed  two  days. 

Physical  examination  showed  a  red  throat,  but  two  cultures,  taken 
November  i8th  and  November  22d,  were  negative  for  diphtheria.  The 
ears  were  also  negative;  no  stiffness  of  the  neck;  no  glandular  enlarge- 
ment. The  mucous  membrane  of  the  mouth  was  normal.  The  chest 
and  abdomen  normal.  The  edge  of  the  spleen  was  felt.  The  urine 
was  free  from  albumin  and  sugar.  There  was  no  edema.  The  blood 
was  normal.     The  chart  was  as  follows: 


Sr:^,yii.^.^.^^.J^.^:iX/.^^^.j  .M.i..i  :iyl.l,^,■J,h. 

p  ........ 77- ■-^:.^-,^....-^' 

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Fig.  85. — Chart  of  case  220. 


FEVERS 


417 


Discussion. — The  fevers  of  children  give  rise  to  far  more  diagnostic 
difi&culties  than  those  of  adults.  Children's  temperatures  undergo 
far  wider  and  more  numerous  oscillations  in  perfect  health  than  adults' 
temperatures.  Besides  these  supposedly  normal  variations,  there  are 
a  great  many  short  periods  of  pyrexia  occurring  in  children  \vho  are  more 
or  less  out  of  sorts  without  any  reason  at  present  assignable. 

In  addition  to  the  variations  just  alluded  to,  children  are  suljjcct  to 
many  fevers  lasting  several  da}-s  "with  nothing  to  show  for  them" — 
i.  e.,  without  any  obvious  local  jjhysical  signs  and  without  any  com- 
plaint to  direct  our  search  to  any  organ  or  tissue.  Among  the  commoner 
causes  ultimately  discovered  for  such  fe\ers  are: 

(a)  The  onset  of  the  exanthemata. 

(b)  Infections  of  the  heart  and  ])ericardium,  with  or  without  joint 
pains  {"  rheumatic  "). 

(f)  Otitis  media  (without  any  discharge  or  complaint  on  the  child's 
part). 

((/)  Urinary  infections  C' jjyelitis,"  ascending  or  hematogenous). 
(e)  Empyema  (without  ])ain,  cough,  or  dyspnea). 
(/)  Poliomyelitis. 

(g)  Tuberculous  meningitis. 
(//)  T}phoid  fe^■er. 

In  all  such  cases  the  best  that  we  can  do  is  to  make  repeated  and 
comprehensive  examinations  of  the  child,  who  is  meantime  kej)t  in  bed. 
given  an  easily  digested  diet  and  plenty  of  water  to  drink.  Sooner  or 
later,  if  we  are  vigilant,  something  comes  to  light.  The  ])oints  neglected 
in  the  present  case  will  be  ob^•ious  from  the  outcome. 

Outcome. — On  the  twenty-fourth  re])eated  examinations  from  liead 
to  foot  still  showed  no  cause  for  her  illness.  She  slept  and  ate  fairly 
well,  and  took  an  interest  in  what  went  on. 

November  29th:  "Se\"eral  nights  ago  she  complained  of  |>ain  in  the 
left  leg.  Next  morning  the  left  knee-jerk  was  al)sent,  the  right  easily 
obtained.  It  was  found  that  the  child's  mother  liad  been  l)ringing  her 
chcxrolate  candy  and  that  the  child  had  eaten  about  a  (juarter  of  a  pound 
of  it,  hiding  the  box  at  night  under  lier  bed-clothes." 

That  night  her  urine  was  re])orted  to  be  full  of  non-ni(ttilc  bacilli 
resembling  colon  bacilli. 

December  8th:   "I'he  knee-jerk  on   the  left   is   sometimes  pnstnt. 

sonii'times  absent,  sometimes  obtained  after  long  trials.     ( >n  walking  the 

child  drags  the  left  foot  ever  so  little.     There  is  no  muscular  atro])hy. 

A  considerable  amomit  of  j)us  a])j)eared  in  the  urine  on  the  fifth  of  Diceni- 

2: 


4iJ 


DIFFERENTIAL   DIAGNOSIS 


ber,  and  this  has  increased  since.  Urotropin,  5  grains  thrice  daily,  and 
abundant  water  were  given." 

On  the  twenty-fourth  of  December  a  little  drooping  of  the  left  shoul- 
der was  perceptil^Ie,  and  the  left  foot  still  dragged  a  little. 

January  2d,  the  urine  ]:)eing  free  from  abnormalities,  the  child  was 
discharged  well. 

Diagnosis. — Poliomyelitis;  renal  infection. 

Case  221 

An  Irish  laborer  of  eighteen  entered  the  hospital  May  20,  1908.  On 
the  recommendation  slip  from  the  out-patient  is  written:  "Appendicitis? 
Typhoid?  Tuberculosis?  "  His  father  and  one  brother  died  of  phthisis. 
The  past  history  is  good.     On  the  fourth  of  December  he  began  to  have 


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pain  in  the  stomach,  which  has  kept  him  awake  at  night  ofT  and  on  ever 
since.  There  is  no  \-omiting;  no  appetite.  He  has  also  been  coughing 
for  the  same  period,  with  a  good  deal  of  sputa. 

Physical  examination  shows  slight  emaciation,  enlarged  tonsils,  es- 
pecially the  right,  but  no  exudate.  The  heart  is  normal.  The  lungs 
show  a  few  scattered  crackles  and  squeaks.  The  right  half  of  the  ab- 
domen is  slightly  more  resistant  than  the  left,  and  in  the  region  of  the 
cecum  there  are  marked  local  tenderness  and  a  mass  about  the  size  of  an 
egg.     The  edge  of  the  spleen  is  just  felt  on  full  inspiration,  likewise  the 


FEVERS  ^jg 

edge  of  the  liver.  The  knee-jerks  are  obtained  with  difficulty.  There 
are  old,  irregular  scars  on  the  backs  of  both  hands  and  at  the  lower  end  of 
the  right  ulna.     Leukocytes,  2800. 

At  no  time  was  there  any  considerable  abdominal  spasm.  By  Mav 
2  2d  the  tenderness  in  the  abdomen  was  gone. 

Discussion. — Remembering  the  great  susceptibility  of  the  Irish 
to  tuberculosis,  the  patient's  family  history,  and  the  long  persistent  cough 
of  which  he  complains,  we  cannot  but  consider  the  possibility  of  a 
tuberculosis,  pulmonary  or  generalized.  The  signs  in  the  lungs  are  con- 
sistent with  miliary  tuberculosis,  but  not  in  any  way  characteristic  of 
that  or  of  any  other  pulmonary  affection.  The  sputa  should,  of  course, 
be  repeatedly  examined.  (This  was  done,  but  with  negative  results.) 
A  tuberculin  reaction  might  be  tried,  but  would  be  significant  only  in 
case  it  was  negative,  as  the  vast  majority  of  adults  react  positi\ely, 
owing  to  the  latent  obsolete  foci  of  tuberculosis.  Had  the  disease  been 
of  the  ordinary  pulmonary  form,  the  signs  in  the  lungs  should  have  been 
more  extensive,  in  view  of  the  long  duration  of  the  cough. 

Tuberculous  peritonitis  with  glandular  masses  and  adherent  coils  of 
intestine  near  the  cecum  might  ex])lain  many  of  the  symptoms,  though 
one  would  expect  more  abdominal  s])asm  and  tenderness. 

Appendicitis  must,  of  course,  be  considered,  though  the  local  signs  are 
few  and  slight,  and  the  cough  and  splenic  enlargement  could  not  be  thus 
explained.  The  leukocyte  count  is  also  surprisingly  low  for  appendi- 
citis. 

The  scars  upon  the  ])ack  of  the  hands  and  on  the  right  forearm  re- 
semble those  sometimes  j)roduccd  by  sy]jhilis.  The  splenic  and  he])atic 
enlargement,  the  cough,  and  fever  might  thus  be  explained,  and  the 
absence  of  any  history  of  this  infection  is  of  no  im])ortance.  Without 
further  evidence,  however,  one  would  not  resort  to  the  therapeutic  test, 
at  any  rate  until  otlier  probabilities  had  been  excluded. 

The  diagnosis  of  tyj)hoid  fe\'er  would  ex])lain  the  i)resent  symptoms 
verv  well.  Many  cases  of  typhoid  exhibit  a  certain  amount  of  tenderness 
in  the  a])])endix  region,  and  this  ])aticnt's  lung  signs  are  those  usually 
found  in  ty])hoid.  We  are  ])U/zlecL  however,  to  ex])lain  the  long  duration 
of  sym])tonis.  Tliis  man  can  hardly  ha\e  had  t}]i]i()id  from  DccemhcT 
4t]i  to  May  20th.  and  if  we  suppose  the  t}-phoid  to  ha\"e  begun  more 
recently,  we  have  no  means  of  coniecturing  what  other  disease  he  may 
ha\e  had  ])reviously.  Kxidentlv,  what  we  most  need  at  tlie  inisent 
juncture  is  a  Widal  reaction  aiKl  blood  culture. 

Outcome.- The  Widal  reaction  was  found  to  be  ])ositiM'  Ma}  joth, 
and  typhoid  bacilli  were  isolated  at  the  same  time  from  the  ear  lilood. 


420 


DIFFERENTIAL   DIAGNOSIS 


The  course  of  the  disease  thereafter  was  uneventful, 
home  perfectly  well  on  the  fourteenth  of  July, 
Diagnosis.— Typhoid  with  relapse. 


The  patient  went 


Case  222 

A  salesman  of  nineteen  entered  the  hospital  June  22,  1908,  with  a 

negative  family  history  and  good  habits.     Four  months  ago,  in  Georgia, 

he  had  a  fever  which  kept  him  in  bed  for  six  weeks  and  a  half.     The 

blood  was  not  examined.     He  had  been  given  capsules  with  considerable 

relief.     Six  days  ago  he  had  a  chill,  followed  by  headache,  fever,  and 

nosebleed.     Four  months  ago  he  weighed 

154  pounds,  now  he  weighs  124  pounds. 

Physical    examination    showed    a    soft 

systolic  murmur,  heard  all  over  the   pre- 

cordia,  w^hile  the  first  sound  at  the  apex 

was  very   faint.     The    pulmonic    second 

was  greater  than  the  aortic  second  sound. 

There  was  no  enlargement  or  irregularity. 

The  arteries  were  palpable  between  beats. 

Liver  dulness  extended  from  the  sixth  rib 

to   a   point  two    inches  below  the  costal 

margin  in  the  parasternal  line.     The  soft 

edge  of  the  sj^leen  was  felt  on  inspiration. 

The  course  of  the  temperature  is  shown 

in   the   accompanying   chart.     The  white 

cells  were  4300.     \Mdal  reaction  negative. 

No  malarial  parasites  were  found  in  the 
Fig.  87. — Chart  of  case  222.        11       1 

Discussion. — Estivo-autumnal  malaria  is  naturally  our  first  guess 
in  the  case  of  a  febrile  patient  who  has  recently  returned  from  Georgia, 
but  this  is  at  once  ruled  out  by  the  negative  examination  of  the  blood  ^ 
and  the  good  condition  of  the  patient.  If  he  had  had  estivo-autumnal 
malaria  in  his  system  for  four  months,  his  S])leen  would  have  been 
harder  and  ]jrobably  larger,  his  general  condition  worse. 

Endocardial  fever  is  suggested  Ijy  the  [presence  of  a  cardiac  murmur 
and  long  duration  of  sym])toms,  but  the  leukocytes  are  rarely  so  few  in 
this  disease,  and  the  murmur  may  well  be  explained  as  "functional." 

\\'hat  inference  sliould  be  drawn  from  the  extension  of  liver  dulness 

'  Very  rarely  malarial  parasites  are  not  to  be  found  in  the  peripheral  circulation  at  a 
sinj^lc  examination  during  the  febrile  stage  of  estivo-autumtial  malaria.  I  have  known  of 
but  one  such  case. 


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FEVERS 


421 


two  inches  below  the  costal  margin?  Should  we  consider  some  of  tlie 
hepatic  diseases  which  are  often  associated  with  fever  (hepatic  syphilis, 
abscess,  cholangitis,  leukemia)?  I  think  not,  for  we  have  no  good 
reason  to  believe  that  the  liver  is  enlarged.  The  extension  of  dulness 
below  the  costal  margin  should  never,  in  my  opinion,  be  taken  as  c\i- 
dence  of  hepatic  enlargement  unless  the  edge  of  the  organ  is  also  palpa- 
ble. Dulness  below  the  right  ribs,  continuous  with  that  of  the  liver, 
is  to  be  found  in  countless  cases  which  ne\'er  show  any  other  evidence 
of  hepatic  enlargement. 

The  loss  of  thirty  pounds  in  four  months  makes  us  suspect  tuber- 
culosis hidden  somewhere  in  the  body,  but  there  seems  to  be  no  good 
e^"idence  to  support  this  suspicion,  though  tuberculosis  cannot  be 
positively  excluded. 

We  must  ask  ourselves  the  question,  Can  this  be  the  "fag-end"  of 
a  typhoid  despite  the  absence  of  a  Widal  reaction?  The  time  of  year 
is  not  at  all  the  usual  one  for  such  an  infection,  and  at  first  sight  we 
should  suppose  that  after  so  long  an  illness  the  patient  would  either 
be  well  or  dead  if  he  had  had  typhoid  all  that  time.  Experience  shows, 
however,  that  just  such  a  history  of  long,  indefinite  illness  is  to  be  ob- 
tained in  many  cases  which  turn  out  e\"entually  to  be  unmistakable 
typhoid.  No  one,  so  far  as  I  know,  has  adequately  accounted  for  this 
fact,  but  no  one  who  has  seen  much  typhoid  will  dispute  it.  It  is  com- 
monly explained  by  saying  that  the  patient  has  probably  had  most  of 
his  typhoid  before  he  came  under  observation,  and  that  what  we  are 
seeing  represents  the  end  of  a  relapse — perhaps  the  second  or  third 
relapse  that  he  has  had.  This  is  perhaps  the  most  plausible  explana- 
tion, although  we  should  expect  the  patient  to  be  much  more  exhausted 
as  we  recall  the  appearance  of  patients  who  have  had  two  or  three 
relapses  under  treatment.  We  must  reject  the  blasphemous  thought  that 
the  patient  mav  1)e  in  good  condition  because  he  has  had  no  treatment. 

The  ])rcsent  case,  however,  is  hard  to  cx])lain,  e\'en  by  this  rather 
far-fetched  hyj^othesis,  for  he  had  his  six  weeks  and  a  half  of  fever  four 
months  ago,  and  has,  since  that  time,  been  up  and  al)out  liis  business 
until  he  was  suddenly  seized  with  a  chill  on  June  i6th.  It  remains 
to  me  a  mystery,  although  a  very  familiar  one,  many  examples  of  which 
1  see  each  autumn  when  patients  in  the  ty])hoid  ward  relate  ver}"  cir- 
cumstantially the  course  of  an  illness  which  has  lasted  all  summer. 

Outcome.- On  the  twenty-fourth  of  June  tlie  Widal  reaction  v\as 
])Ositi\e.  The  ])atient  was  out  of  bed  July  loth  and  discharged  well 
on  July  i<Sth. 

Diagnosis. — Ty])li()id  (brief). 


422 


DIFFERENTIAL   DIAGNOSIS 


Case  223 

An  Italian  laborer  of  twenty-eight  entered  the  hospital  September 
23,  1906.  His  family  history,  past  history,  and  habits  are  good.  Three 
weeks  ago  he  went  to  bed  with  a  headache  and  has  been  there  ever 
since.  His  appetite  is  good,  but  he  has  not  been  allowed  to  eat  much. 
His  bowels  have  been  constipated.  There  has  been  no  cough.  He  has 
had  three  nosebleeds. 

On  physical  examination  the  pupils  were  found  to  be  slightly  irregular, 
the  right  larger  than  the  left.  Both  reacted  normally.  The  glands  in 
the  neck,  axillae  and  groins  were  palpable,  but  not  enlarged.      Physical 


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examination  was  otherwise  ncgati\-e,  also  the  urine.  The  eye-grounds 
were  normal.     White  cells,  7000. 

Discussion. — One's  lirst  impression  would  be  that  there  is  really 
not  much  the  matter  with  this  man.  His  temperature  is  practically 
normal,  his  organs  negative  to  j)hysical  examination.  But  on  second 
thought  we  must  recognize  that  a  young  Italian  laborer  does  not  stay 
in  bed  three  weeks  for  the  fun  of  it.  Something  must  be  the  matter  with 
him,  and  his  doctor  sa}s  that  he  has  had  a  fever. 

A  very  considerable  proportion  of  Italian  laborers  appear  to  have 
had  syphilis.  The  irregularity  of  the  ])upils  and  the  palpable  glands 
seemed  to  su])])ort  this  idea;  but  it  was  not  possible  to  get  beyond  the 


FEVERS 


423 


region  of  conjecture  as  regards  syphilis,  for  the  Wassermann  reaction 
was  not  then  in  use. 

The  slow  pulse  and  the  rather  persistent  headache  might  be  taken 
as  evidence  pointing  toward  brain  tumor  or  other  cerebral  lesions;  but 
this  suggestion,  like  the  others,  had  to  be  left  hanging,  as  there  were  no 
sufficient  grounds  for  a  more  positive  decision. 

At  this  time  of  year  and  in  a  patient  with  this  history  it  is  always 
advisable  to  try  a  Widal  reaction.  The  result  of  it  was,  in  this  case, 
extremely  interesting,  as  is  indicated  by  the  outcome. 

Outcome. — The  Widal  reaction  was  strongly  positi\"e  at  entrance. 
The  later  course  of  the  temperature  is  shown  in  Fig.  88.  The  patient 
went  home,  apparently  well,  on  the  twenty-second  of  October^ 

Diagnosis. — Typhoid  (afebrile  when  first  seen). 

Case  224 

A  housewife  of  thirty-seven  was  seen  March  16,  1907.  Her  family 
history  was  good.  She  has  never  been  sick  before.  She  has  been  nursing 
her  twelve-year-old  girl,  who  has  been  sick  for  three  weeks  with  fever, 


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I'ig.  8y. — Chart  nf  lasc  224. 


diarrhea,  thirst,  and  stupor.  Yesterday  her  l)()y  of  fourteen  was  also 
taken  sick.  She  has  felt  tired  from  nursing  her  children,  but  did  not  call 
herself  sick  until  the  doctor  took  her  temperature  at  6  p.  \i.  tcvday,  and 


424 


DIFFERENTIAL   DIAGNOSIS 


found  it  102°  F.  She  sleeps  well,  but  is  constipated  and  has  a  rather 
poor  appetite. 

Examination  showed  an  obese,  apathetic  woman,  her  scalp  co\ered 
with  crusts.  A  soft,  blowing  systolic  murmur  was  heard  over  the  pre- 
cordia,  loudest  in  the  pulmonary  area.  The  pulmonic  second  sound  was 
accentuated,  the  heart  not  enlarged.  The  lungs  and  abdomen  were 
negative.  White  cells,  4600;  Widal  reaction  negative.  The  bowels 
moved  daily.  On  the  twenty-sixth  she  began  to  suffer  from  diarrhea 
with  distressing  tenesmus,  which  lasted  three  days,  and  on  the  same  day 
she  passed  a  small  amount  of  blood,  the  pulse  not  being  at  all  affected. 

On  the  t\vent}--eighth,  rectal  examination  revealed  a  large  mass  of 
feces  just  inside  the  anus.     Removal  of  this  relieved  all  the  symptoms. 

On  the  third  of  April  she  complained  of  a  burning  micturition.  The 
urine  showed  nothing  abnormal  except  extreme  acidity.  Citrate  of 
potassium  and  cream  of  tartar  water  promptly  relieved  this  symptom. 
She  was  discharged  well  on  the  twenty-seventh. 

Discussion. — When  a  woman  has  a  fever  and  nothing  to  show  for  it; 
when  the  leukocytes  are  subnormal  and  two  others  in  the  same  family 
have  febrile  illnesses,  the  chances  are  strongly  in  favor  of  the  assump- 
tion that  she  has  typhoid  fever,  probably  acquired  by  contact.  In  the 
present  case  the  W'idal  reaction  appeared  March  20th,  but  the  diagnosis 
was  easily  made  before  that. 

The  case  is  introduced  here  to  exemplify  the  occurrence  of  diarrhea 
and  tenderness  due  to  fecal  impaction  in  typhoid  fever,  even  though  the 
bowels  had  been  moving  daily.  Such  cases  are  not  at  all  uncommon,  and 
if  rectal  examination  is  neglected,  the  trouble  is  rarely  recognized,  and 
may  cause  much  suffering.  It  usually  occurs  toward  the  end  of  the  case, 
at  or  near  the  period  of  defervescence,  coming  on  quite  suddenly  and 
without  warning.  The  accumulation  is  often  so  great  that  it  has  to  he 
removed  mechanically.  The  lesson  forced  upon  me  by  my  failure  in  one 
such  case  was  ne^•er  to  neglect  rectal  examination  in  a  case  of  diarrhea. 

Of  some  interest  also  is  the  dysuria,  which  the  therapeutic  tests  ap- 
parently prove  to  ]je  due  to  hyperacidity  of  the  urine. 

Diagnosis. — Tyjjlioid;  impaction;  dysuria. 

Case  225 

A  rubber  worker  of  thirty-se\en,  a  Swede  by  birth,  entered  the 
hospital  June  10,  iqoS.  His  family  history  and  past  history  were  good, 
except  that  he  had  "typhoid"  at  the  age  of  eighteen,  and  "malaria "" 
for  a  week  a  year  ago. 

Two  weeks  ago,  while  at  work,  he  had  a  severe  chill  and  abdominal 


FEVERS 


425 


cramps,  which  doubled  him  up.  After  three  hours  he  went  to  work 
again  and  kept  on  for  the  next  two  days,  when  he  had  to  give  upon  account 
of  weakness  and  pain  in  his  stomach.  He  has  been  in  bed  for  a  week. 
To-day  he  vomited  twice;  he  has  had  no  appetite,  poor  sleep,  moderate 
constipation.  He  has  passed  urine  only  twice  in  each  twenty-four  hours 
during  the  last  two  weeks.     What  he  passes  is  \"ery  red. 

Physical  examination  showed  obvious  loss  of  weight.  Cardiac  dul- 
ness  extended  one  inch  beyond  the  right  border  of  the  sternum.  No 
cardiac  impulse  was  seen  or  felt.  There  was  nothing  abnormal  about 
the  sounds.  The  left  lung  showed  bronchial  respiration  above  the 
clavicle,  bronchovesicular  respiration  and  increased  voice-sounds  down 


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to  the  second  rib.  Below  that  level  \oice-sounds,  breath-sounds,  and 
tactile  fremitus  were  diminished;  ])crcussion  was  dull  to  flat.  The  alxlo- 
men  was  quite  negatixe.     The  white  cells  were  7400:  the  urine  negatiw. 

The  chest  was  ta])pcd  cm  the  ele\"enth  and  40  ounces  of  clear.  ]>alt' 
yellow  fluid  remoxcd.  Sj)eciric  graxit}-,  1017;  albumin,  2.8  per  ((.nl.; 
lym])hocytes,  (;7  ])er  cent. 

On  the  sixteenth  64  ounces  more  were  remox-ed  from  the  rlu>i.  '  Mi 
tlie  twentietli  it  was  tap])ed  a  third  time,  l)ut  onlv  10  ounces  IhmkI. 
( )n  tlie  twenty-eighth  it  was  again  ta])pe(l  and  70  ounces  wen-  ri-iiM\,(l. 
Mis  weight  a  month  l)ef()re  entering  the  h()S]Mtal  was  155  ]K)l!^(l^.  At 
the  time  of  his  discharge  it  was  124  ])<)un(is. 


426  DIFFERENTIAL    DIAGNOSIS 

Discussion. — In  rubber  workers  we  meet  with  all  sorts  of  obstinate 
and  debilitating  symptoms  which  oftentimes  refuse  to  be  grouped  into 
any  recognizable  disease,  although  lead  colic  sometimes  emerges  from 
the  obscurity,  in  case  the  workers  deal  with  that  part  of  the  process  of 
manufacture  in  which  lead  is  used.  But,  so  far  as  I  am  aware,  none  of 
the  toxic  effects  of  work  in  a  rubber  factory  produces  fever. 

The  patient's  account  of  himself  gives  us  no  inkling  of  what  may  be 
the  cause  of  the  fe\er.  Physical  examination  and  the  results  of  aspira- 
tion leave  no  doubt  that  the  patient  has  been  sulTering  from  a  pleural 
etTusion.  It  is  unusual,  however,  to  observe  so  rapid  a  reaccumulation 
of  the  fluid.  In  the  vast  majority  of  cases  of  ordinary  tuberculous  pleur- 
isy a  single  tapping  suffices,  or  if  recurrence  takes  place,  it  is  far  less 
rapid  than  in  the  present  case,  which  suggests  another  and  more  ominous 
possibility. 

Whenever  rapid  and  frequent  reaccumulation  of  pleural  fluid  occurs 
in  a  case  belie^■ed  to  be  one  of  ordinary  (tuberculous)  pleurisy,  we  should 
always  suspect  malignant  disease  of  the  lung,  pleura,  or  mediastinal 
glands,  no  matter  how  young  the  patient  and  despite  the  absence  of  all 
pain.  I  have  t^^■ice  made  the  mistake  of  diagnosing  as  pleurisy  a  case 
which  turned  out  to  be  malignant  disease  with  secondary  effusion.  Malig- 
nant disease  not  infrequently  produces  a  bloody  effusion,  but  this  is  by 
no  means  in^•ariable. 

The  A'-ray  gives  us  usually  but  little  assistance  in  doubtful  cases  of 
this  type,  as  the  collapsed  lung  may  simulate  the  shadow  produced  by 
malignant  disease.  The  cellular  elements  of  the  sediment  may  be  iden- 
tical in  both  diseases.  The  first  clue  obtained  in  most  doubtful  cases  is 
the  appearance  of  a  metastasis  in  one  of  the  external  lymph-glands  or 
elsewhere.  Later  the  steady  decline  in  the  patient's  strength  makes 
it  ob\-ious  that  something  more  serious  than  pleurisy  underlies  the 
eft'usion. 

Outcome. — After  July  28th  there  was  no  further  reaccumulation 
and  the  patient  rapidly  improved.  On  August  6th  he  went  to  Rutland 
Sanatorium. 

Diagnosis. — Pleurisy  (tuberculous). 

Case  226 

A  young  married  woman  of  twenty  was  first  seen  January  27,  1904. 
Two  months  ago  her  second  child  was  born.  Hemorrhage  and  cureting 
followed. 

Fever  and  chills  for  three  "weeks.  (See  Fig.  91.)  No  pain  what- 
ever.    Xo  other  complaints. 


FEVERS 


427 


Physical  examination  negative.  Widal,  negative.  Whites,  7000. 
The  case  was  considered  by  Dr.  R.  H.  Fitz  a  mild  septicemia.  The 
uterus  was  dextroretroverted.  Cervix  very  soft.  Uterine  body  very 
hard.     Culs-de-sac  free.     The  uterus  was  dilated  and  cureted. 

February  19th  vaginal  examination  showed  some  edema  in  right  iliac 
region. 

Discussion. — This  woman  complained  of  nothing  in  the  world  but 
fever.  As  she  had  rather  recently  emigrated  from  Italy,  had  had  re- 
peated chills  and  irregular  fever,  her  blood  was  many  times  examined 
for  malarial  parasites,  but  none  were  found. 

After  this,  typhoid  was  considered,  although  the  chart  was  very 
unlike  it,  and  the  patient  showed  at  no  time  any  hebetude.     The  Widal 


i-.-i-.-L^444  -«■  ■  ■  ■  '■  -U-Li-:-;-L:.  .4—-  .  :  I  1  ;  I  1 


Tj-ltif 


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Fig.  Qi.^Chart  of  rase  226. 


reaction  was  done  a  number  of  times,  always  with  negati\c  results. 
Nevertheless,  typhoid  could  not  positively  be  excluded. 

Since  the  symptoms  came  on  soon  after  her  confinement,  there 
seemed  good  reason  to  believe  that  the  case  might  be  one  of  mild  sep- 
ticemia, pelvic  in  origin.  The  dilating  and  curetage  were  done  with 
this  idea  in  mind,  but  no  improvement  followed,  and  the  diagnosis 
remained  altogether  in  doubt. 

Mesenteric  and  ])eritoncal  tuberculosis  arc  cs])ecially  common  in 
recent  immigrants  of  the  Italian  race,  and  it  is  im])()ssiblc  to  exclude 
this  diagnosis,  though  there  were  no  signs  of  fluid  in  the  peritoneal 
cavity,  no  palpa]:>le  glandular  masses,  and  only  a  moderate  gciUTal 
abdominal  sj)asm,  rather  more  marked  in  the  lower  half. 

Outcome. — The  ])atient  was  examined  under  ether  on  the  t\M'Uty- 
third  of  I-\'l)ruar}'.  and  a  mass  was  feU  in  the  region  of  the  cecum.  The 
abdomen  was  then  o])ened.  and  the  mass  found  to  consist   of  caseous 


428 


DIFFERENTIAL   DIAGNOSIS 


glands  intimately  adherent  to  the  cecum.  Microscopic  examination 
proved  tuberculosis.  After  a  long  illness  the  patient  finally  made  a 
perfect  recovery. 

Diagnosis. — Pericecal  tuberculosis. 

Case  227 

A  car])enter  of  twenty-seven  entered  the  hospital  February  17,  1907, 
with  an  excellent  family  history  and  past  history.  He  drinks  one  or 
two  pints  of  beer  a  day,  rarely  a  glass  of  whisky.  His  habits  are  other- 
wise good. 

Two  weeks  ago  he  "got  a  cold,"  and  felt  sick  enough  to  go  to  Ijed, 
although  free  from  pain.     Since  then  he  has  had  a  slight  cough  and  has 


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Fip.  Q2. — Chart  of  case  227. 


raised  a  little  s])uta,  which  he  describes  as  black  and  white.  He  says 
he  feels  tired  all  over,  and  for  the  past  three  days  has  had  some  pain 
in  the  right  axilla  and  in  the  region  of  the  right  nipple,  not  increased  by 
deep  breatliing.  To-day  liis  only  complaint  is  of  weakness.  His 
appetite  is  good,  his  l)owels  regular,  but  he  thinks  he  has  lost  much 
weight.     (For  the  temperature,  see  the  accompanying  chart.) 

On  physical  examination  the  heart  showed  nothing  abnormal. 
Tlie  left  lung  was  ncgati^■e,  sa\e  for  a  few  scattered  rales.  Throughout 
the  right  lung  fine  crackles  were  heard,  with  slightly  diminished  voice- 


FEVERS 


429 


sounds,  except  at  the  apex,  where  they  were  slightly  increased,  with 
a  little  dulness  on  percussion.  The  edge  of  the  li\er  was  felt  one  finger's 
breadth  below  the  ril)S.  Physical  examination,  including  two  examina- 
tions of  sputa,  was  otherwise  negative.  The  Widal  reaction  was  always 
negative.  The  leukocytes  numbered  12,400  on  February  17th;  13.000 
on  February  i8th;    16,500  on  February  22d;    11,900  on  February  26th. 

Discussion. — It  seems  natural  to  associate  the  fever  and  the  rather 
indefinite  pulmonary  signs  as  cause  and  effect,  but  it  is  hard  to  see 
how  these  signs  can  be  considered  sufficient  to  represent  a  ])neumonia, 
an  acute  pulmonary  tuberculosis,  or  an  empyema,  which  are  about  the 
only  lung  diseases  one  would  think  of  in  this  connection.  Tuberculosis 
seems  perhaps  the  more  probable  of  the  three,  but  we  ha\e  no  }X)sitive 
evidence  of  this  in  the  sputa  or  elsewhere. 

Let  us  attack  the  problem  from  a  dilTcrent  point  of  view.  As  I  have 
elsewhere  shown, ^  there  are  but  three  obscure  continued  fevers  in  New 
England  which  last  over  two  weeks — ty])hoid,  tuberculosis,  and  |)yo- 
genic  infections  (sepsis).  TJie  o/Jier  fevers,  such  as  those  due  to  menin- 
gitis, to  acute  articular  rheumatism,  to  leukemia,  ])ernicious  anemia, 
syj)hilis,  or  malignant  disease,  are  rarely  '" obscure'^ — that  is,  they  show, 
as  a  rule,  some  obvious  local  lesions  as  their  cause.  Returning  then  to 
our  case  with  this  clue,  it  seems  that  we  may  exclude  ty})hoid  because 
of  the  continued  leukocytosis,  the  continued  absence  of  the  Widal 
reaction,  the  excellent  api)ctite,  the  aljscnce  of  splenic  enlargement,  and 
the  time  of  year. 

Sei)sis  is  not  so  easily  excluded,  but  tlie  great  majority  of  cases  show 
either — (a)  a  definite  localized  focus  or  source  of  infection,  or  (b),  in 
the  absence  of  such  focus,  a  much  more  serious  clinical  ])icture.  This 
patient  does  not  seem  much  sick,  especially  when  we  com])are  his  con- 
dition with  that  of  ])atients  with  generalized  pyogenic  infection  without 
demonstrable  source. 

Can  jnilmonary  tuberculosis  which  siiows  its  ])resence  l)y  signs  as 
slight  and  as  few  as  in  the  present  case  be  }"et  resjionsible  for  such 
marked  and  continued  pyrexia  ?  Experience  siiows  that  it  can.  Nothing 
is  more  remarkable,  as  one  studies  a  large  series  of  cases  of  pulmonar}' 
tuberculosis,  than  the  discrej)ancies  l)etwcen  the  amount  of  lung  iinohed 
and  the  amount  of  constitutional  disturl)ances,  such  as  fe\er,  ])r()stra- 
tion,  emaciation,  indigestion.  Some  patients  in  whose  lungs  two  or 
three  lobes  are  olniously  infiltrated  feel  scarcely  sick  at  all.  and  kt'ep 
about  their  work  for  many  months.  ()thers,  in  whom  we  can  scaicely 
disco\er   enough    j^hysical    signs    to   assure    tlie   diagnosis,    are    utterly 

'  Sec  Reference  on  p.  -lo.v 


430 


DIFFERENTIAL   DIAGNOSIS 


prostrated,  drenched  with  sweats,  constantly  febrile,  unable  to  digest, 
and  rapidly  emaciate.  Presumably  these  differences  are  due  in  part 
to  the  variations  in  individual  resistance,  in  part  to  the  nature  of  the 
secondary  infection  ingrafted  upon  the  original  tuberculosis. 

Outcome. — After  many  examinations  tubercle  bacilli  were  finally 
demonstrated  February  25  th  in  a  small  speck  of  mucus  which  accom- 
panied about  30  c.c.  of  fresh  blood.  No  typical  signs  of  solidification 
appeared  until  ]\Iarch  6th.     March  13th  he  was  discharged  worse. 

Diagnosis. — Phthisis. 

Case  228 

A  teacher  of  thirty-four,  of  good  family  history,  entered  the  hospital 
December  17,  1906.     He  had  been  told  about  eight  years  ago  that  he 


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Fig.  93. — Chart  of  case  228. 


had  a  weak  heart.  He  had  gonorrhea  fi\"e  years  ago,  syphilis  eight 
years  ago. 

Five  weeks  ago  he  "took  cold,"  had  a  slight  cough  and  fever,  occa- 
sionally a  little  pain  in  the  right  knee,  later  in  various  other  parts  of  the 
body,  never  constant  or  definite.  He  kept  at  work  until  five  days  ago, 
when  he  took  to  bed  on  the  ad\-ice  of  his  physician.  He  now  feels 
some  aching  all  over  his  body;   he  has  no  appetite,  much  constipation. 

The  palpable  cardiac  impulse  extends  as  low  as  the  sixth  s|)ace 
in  the  nipple  line.     There  is  harsh,  systolic  murmur,  best  heard  at  the 


FEVERS 


431 


apex,  but  also  audible  all  over  the  chest.  The  pulmonic  second  sound 
is  slightly  accentuated.  Dr.  H.  F.  Vickery,  who  had  previously  seen 
him,  stated  that  this  murmur  has  been  here  for  at  least  fourteen  years. 
Physical  examination  is  otherwise  negative  except  for  a  leukocytosis 
of  19,200,  and  a  fever  ranging  between  101°  and  103°  F.     (See  Fig. 

93-) 

On  December  23d,  slight  dulness  and  slight  increase  of  voice  were 
made  out  at  the  left  pulmonary  apex.  The  patient  says  he  has  worked 
very  hard  for  more  than  a  year  and  is  tired  out.  He  now  sleeps  most 
of  the  time,  but  complains  of  no  discomfort. 

There  was  no  change  in  his  condition  for  the  next  month.  He 
remained  cheerful,  his  sleepiness  gradually  wore  off  and  his  appetite 
returned,  but  he  continued  to  have  fever. 

Pneumovaccines  were  given,  beginning  March  17th,  but  produced 
no  improvement.  After  the  12th  of  March  the  temperature  became 
subnormal,  and  remained  so  for  most  of  the  following  month,  though 
the  leukocyte  count  was  ])crsistcntly  high,  varying  between  10,000  and 
34,000.  On  the  twenty-fourth  of  March  the  red  cells  were  3,012,000, 
the  hemoglobin,  50  per  cent.  Of  the  white  cells,  92  per  cent,  were  poly- 
nuclear  and  the  rest  lymphocytes. 

Discussion. — Another  case  exhibiting  at  the  time  of  entrance  a  jevcr 
and  nothing  else.  The  constant  leukocytosis  makes  it  possible  to 
exclude  typhoid,  and  the  other  features  of  the  examination  rule  out 
j)ractically  everything  else  except  tuberculosis  and  some  form  of  pyo- 
genic infection.  The  patient  slept  so  large  a  portion  of  his  time  during 
the  first  month  of  his  stay  in  the  hospital  that  meningitis  was  at  times 
sus]3ected,  but  at  no  time  were  there  any  physical  signs  tending  to 
confirm  this  suspicion. 

The  pulmonary  signs  described  under  the  date  of  December  23d  arc 
such  as  arc  found  in  a  great  numIxT  of  sick  ])eoi)le  if  the  examination  is 
conducted  with  the  utmost  care  in  a  quiet  room.  At  the  right  apex 
ihcv  would  ha\e  no  significance  whatever.  At  the  left  they  call  for 
more  consideration,  but  are  not  in  themselves  sufiicient  to  make  us 
seriously  fear  jmeumonia  or  tuberculosis. 

Whenever  a  continued  fe\cr  accom()anics  a  cardiac  murmur  sucli 
as  that  here  descril)e(l,  tliere  is  reason  to  fear  that  a  vegetati\e  endo- 
carditis is  at  work.  But  in  the  present  case  we  ha\e  reason  to  l)elic\e 
that  the  murmur  lias  existed  for  at  least  fourteen  years,  so  that  its 
association  witli  tliis  fe\er  may  not  Ijc  significant.  On  the  other  liand. 
the  severe  secondary  anemia  and  the  constant  leukocytosis  giw  us 
reason  to  believe  that  the  old  ])rocess,  which  was  recognized  u])on  the 


432 


DIFFERENTIAL   DIAGNOSIS 


mitral  valve  fourteen  years  ago,  has  again  become  active,  like  some 
hitherto  quiescent  volcano. 

Outcome. — Beginning  with  March  29th,  he  had  a  great  deal  of 
vomiting,  the  vomitus  containing  considerable  blood  on  one  occasion. 
At  this  time  there  was  little  or  no  pulse  to  be  felt  in  the  right  arm,  although 
in  the  left  it  was  fairly  strong.  Vomiting  ceased  within  a  few  days, 
but  the  patient  was  left  exceedingly  emaciated  and  weak.  Two  pur- 
plish areas  developed  April  14th  on  the  dorsum  of  the  left  foot;  they 
disaj)peared  during  the  day.  Another  appeared  ofi  the  heel  in  the 
same  afternoon.  The  patient  began  to  be  delirious  about  this  time 
and  he  died  on  the  twenty-first  of  April. 

Autopsy  showed  polypous  endocarditis  of  the  mitral  valve;  multiple 
infarcts  of  the  spleen  and  kidneys;  hypertrophy  and  dilatation  of  the 
heart. 

Diagnosis. — Alalignant  endocarditis. 

Case  229 

A  housewife  of  sixty-seven  entered  the  hospital  February  10,  1909. 
She  has  seemed  to  be  {)erfectly  well  until  this  morning,  although  she 
has  noticed  that  her  feet  sv.cW  from  time  to  time,  and  has  been  aware 
that  she  passed  unusually  large  quantities  of  urine.  She  has  had  no 
headache  and  no  vomiting. 

This  morning  she  awoke  at  four  o'clock,  saying  that  she  did  not 
feel  well.  Within  a  short  time  she  had  several  convulsions  and  became 
comatose. 

Physical  examination  showed  a  red,  parched  tongue,  the  heart's 
apex  one  inch  outside  the  nipple  line,  the  action  regular  and  slow; 
there  were  no  murmurs  and  apparently  no  increase  in  pulse  tension,  but 
the  blood-pressure  was  175  mm.  Coarse  and  medium  rales  were 
scattered  throughout  both  lungs. 

During  the  examination  the  patient  had  a  general  clonic  con\'ulsion, 
with  frothing  at  the  mouth,  biting  of  the  tongue,  dilatation  of  the  pupils, 
incontinence  of  urine  and  feces.  The  urine  contained  sugar,  and  had 
a  marked  reaction  for  acetone  and  diacetic  acid.  Gravity,  1021;  albu- 
min, a  slight  trace;  sediment,  negative.  The  blood  showed  25.000 
white  cells  i)er  c.mm. 

The  course  of  the  temperature  is  seen  in  the  accompanying  chart 
(Fig.  94). 

Cheyne-Stokes'  breathing  began  soon  after  the  patient  entered  the 
hospital,  and  the  aortic  second  sound  was  noted  to  be  verv  loud.     There 


FEVERS 


433 


was  no  evidence  of  meningitis,  and  a  blood  culture  was  negative.  Con- 
vulsions followed  each  other  in  rapid  succession. 

Within  an  hour  of  the  time  of  entrance  the  patient  was  bled,  14 
ounces  of  blood  being  taken  from  the  arm,  and  2  pints  of  normal 
salt  solution  containing  5  drams  of  sodium  bicarbonate  were  put  into 
the  vein.  Convulsions,  however,  continued  until  the  eleventh,  when, 
under  copious  sweating  by  means  of  hot-air  baths,  and  subpectoral 
infusions  of  salt  solution,  she  began  to  improve  steadily. 

On  the  thirteenth  she  was  conscious,  though  confused.  Sugar, 
acetone,  and  diacetic  acid  were  gone  from  the  urine,  in  the  sediment 
of  which  many  hyaline,   fine  and  coarse   granular  casts  were  found, 


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some  with  fat  adherent.  The  left  pu|)il  ^\•as  now  larger  than  the  right, 
though  both  reacted  normally. 

On  the  fourteenth  she  was  at  times  rational,  at  times  in  a  muttcriuL: 
delirium.  She  could  swallow  and  took  milk  well,  but  had  no  control 
o\er  the  sphincters,  and  was  occasionall}'  nois}-  aiid  profane.  I'hv 
white  count  had  dro])])cd  to  Sooo. 

On  the  eighteenth  she  had  hallucinations  both  of  sight  and  hearinL^ 
but  when  spoken  to  answered  rationallw 

(^n  the  twenty-second  she  was  u])  in  a  cliair.  free  from  an}'  iKiralx.-is 
or  anesthesia,  c|uite  rational  in  the  dav-time.  altliough  a  little  irrational 
at  niuht.     She  had  now  regained  control  of  the  rectal  siiliincter. 


434  DIFFERENTIAL   DIAGNOSIS 

On  the  twenty-fifth  the  urine  showed  no  casts;  leukocytosis  was 
still  absent.     The  Widal  reaction  was  entirely  negative. 

On  March  9th  she  was  able  to  walk  about  very  well,  and  was 
to  have  gone  home.  At  three  o'clock  she  sank  into  a  chair  with  a  very 
poor  pulse,  and  had  a  short  convulsion,  lasting  only  fifteen  seconds, 
but  followed  by  hallucinations  of  sight  and  hearing.  She  then  sud- 
denly came  to,  remarked  that  she  was  afraid  she  had  made  a  fool  of 
herself,  asked  what  had  struck  her,  and  remained  quiet  and  rational. 

On  ]VIarch  12th  she  was  discharged. 

Discussion. — The  features  of  this  case  may  be  summarized  as  con- 
tinued fever  with  epileptiform  attacks  and  glycosuria. 

The  last  item  may  be  dealt  with  first.  A  patient  seen  for  the  first  time 
with  coma  or  convulsion  should  always  be  catheterized  and  the  urine 
examined  for  all^umin  and  sugar,  yet  I  have  known  a  very  large  number 
of  mistakes  arising  from  an  inference  made  because  either  albumin, 
sugar,  or  both  were  found  to  be  present.  It  should  always  be  remem- 
bered that  convulsions  or  coma,  whatever  their  cause,  frequently  give 
rise  to  glycosuria,  to  albuminuria,  or  to  both  conditions.  One  must 
have  other  evidence  before  concluding  that  diabetes  or  nephritis  is 
present.  Such  evidence  is  to  be  sought  in  the  condition  of  the  heart, 
in  the  previous  history,  and  in  the  result  of  subsequent  examinations 
of  the  urine,  which,  in  the  present  case,  were  negative,  as  indeed  they 
usually  are  in  patients  seen  for  the  first  time  in  convulsions  or  coma. 
The  acetone  and  diacetic  acid  are  not  easily  to  be  accounted  for,  as 
we  have  no  evidence  that  the  patient  has  been  starving  herself,  and 
her  ^'omiting  is  very  recent. 

Subsec{uent  examinations  of  the  urine  showed  no  sufficient  evidence 
of  renal  disease.  A  trace  of  albumin  and  a  few  casts  were  present 
from  time  to  time,  but  the  amount  and  gravity  of  the  urine  were  normal, 
and  in  my  opinion  it  has  been  amply  demonstrated  that  albumin  and 
casts  in  a  woman  of  this  age  are  not  in  themselves  evidence  of  renal 
disease,^  although  they  are  perfectly  consistent  with  such  a  diagnosis, 
and  do  not  in  any  way  exclude  it. 

Attacks  of  convulsions  and  coma  in  an  elderly  person  wliose  heart 
shows  some  e\-idencc  of  enlargement  should  always  lead  us  to  scrutinize 
the  A-eins  of  the  neck  and  to  listen  ^■cry  carefully  oxer  the  ])recordia 

^  Y.  C.  ShaUuck,  Boston  Med.  and  Surg.  Jour.,  1804,  vol.  cxxx,  p.  613:  "  On  the 
Urine  of  Persons  over  l-'ifly  ^'cars  of  Age."  William  Osier,  Xew  ^'ork  Medical  Jour., 
T901,  Ixxiv,  p.  040 :  "  On  the  Advantages  of  a  Trace  of  All)umin  and  a  few  Tube-casts 
in  the  I'rine  of  Certain  Men  AIkivc  l-"ift\-  ^'ears  of  Age." 


FEVERS 


435 


for  evidences  of  heart  block  (Adams-Stokes  disease).     In  the  present 
case  no  such  evidence  was  forthcoming. 

Meningitis  may  begin  as  suddenly  as  this,  with  fever  and  convul- 
sions as  the  chief  evidence  of  its  presence.  (See  Case  266,  p.  508.) 
Although  there  were  no  positive  evidences  of  meningitis  in  this  case, 
lumbar  puncture  was  done,  and  a  sterile  fluid  almost  free  from  cells 
spurted  out  under  considerable  pressure.  No  micro-organisms  could 
be  demonstrated  in  the  sediment.  The  very  transient  character  of  the 
leukocytosis  is  also  evidence  against  any  type  of  meningitis  except  that 
due  to  tuberculosis. 

Typhoid  fever  was  difficult  absolutely  to  exclude.  The  patient's 
age  and  the  time  of  year,  the  initial  leukocytosis  and  the  convulsions — 
all  were  unusual  and  atypical,  but  none  positively  excluded  the  disease. 

Ivooking  over  the  case  as  a  whole,  and  taking  account  of  the  high 
blood-pressure,  the  absence  of  any  focal  symptoms  and  the  intermit- 
tence  of  the  cerebral  manifestations,  it  seems  to  me  that  this  case  may 
best  be  classed  as  one  of  the  group  denominated  by  Pal  as  ^■ascular 
crises  '  of  the  cerebral  form.  Pal's  monograph  (which  docs  not  seem 
to  me  to  have  received  the  attention  which  it  deserves)  describes  in 
detail  a  large  numljer  of  cases  in  which  the  diagnosis  of  cerebral  hemor- 
rhage, embolism  or  thrombosis  would  ordinarily  be  made,  yet  in 
which  the  auto})sy  showed  no  gross  organic  lesion  in  the  brain,  no 
hemorrhage,  softening  or  vascular  occlusion.  He  shows  that  similar 
crises  would  reasonably  be  supposed  to  occur  in  cases  of  lead-poisoning 
(lead  encephalopathy),  in  nephritis  (transient  uremic  hemij)legia, 
aphasia,  or  amaurosis),  as  well  as  in  arteriosclerotic  cases  with  dimin- 
ished elasticity  of  the  vessels  and  high  ])lood-pressure.  Presumably, 
as  he  argues,  the  colic  of  lead-])oisoning,  the  gastric  crises  of  tabes 
dorsalis,  and  many  of  the  acute  attacks  of  alxlominal  ])ain  occurring 
without  any  other  exjjlanation  in  arteriosclerotics  may  be  likewise 
ex])lained  as  abdominal  N'ascular  crises,  while  the  various  forms  of  angina 
])ectoris  and  of  intermittent  claudication  may  reasonably  l)e  considered 
as  ])ectoral  or  ]jeri])heral  crises  of  the  same  type.  Vascular  spasm  is 
in  all  cases  assimied  as  the  fundamental  change. 

Diagnosis. — X'ascular  crisis. 

Case  230 

A  girl  three  years  old  entered  the  li()S])ital  May  5,  i()oS.  'ilie 
child  was  perfectly  well  until  the  da}'  before,  wlicu  xoiniting,  headache, 
and   abdominal    pain    were   con"i])laine<l    ot.      Last    night    the    xoiniting 

'  ( 'icfrisskricscn,  J.   Tal,  I.irpsic,    1005   (S.    Ilir/rH. 


436 


DIFFERENTIAL    DIAGNOSIS 


continued,  although  she  took  food  well.  The  bowels  were  natural  and 
there  were  no  con\ulsions. 

Physical  examination  showed  nothing  wrong  in  the  throat  or  ears, 
a  normal  heart,  a  slight  dulncss  at  the  right  apex  extending  down  to 
the  third  rib  in  front  and  to  the  spine  of  the  scapula  behind.  Over  this 
area  there  was  bronchial  breathing  and  increased  fremitus. 

The  course  of  the  temperature  was  as  seen  in  the  accompanying 
chart  (Fig.  95). 

White  count,  38,400  on  May  5th;  50,000  on  May  7th;  79,200  on 
May  13th;  69.000  on  May  i6th;  39,000  on  May  i8th;  23,000  on  May 
20th;    17,000  on  May  23d. 


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On  the  ninth  of  May  the  lower  left  lobe  became  likewise  in\olvcd. 
On  the  eighteenth  an  aural  consultant  found  double  otitis  media  and 
opened  both  drums.  On  the  twentv-second,  though  both  cars  were 
discharging  freely,  the  lem])erature  still  remained  high.  Dulness  and 
diminished  breathing  were  then  discovered  at  the  right  base. 

The  cluld's  general  appearance  was  \"ery  poor. 

On  the  twenty-fourth  the  dulncss  and  diminished  respiration  at  the 
right  base  had  increased,  althougli  there  were  no  signs  of  an^'thing 
abnormal  in  the  front  of  tlie  chest.  A  needle  introduced  into  the  back 
drew  ])us  containing  many  extracellular  ])neumococci.  A  ]nire  culture 
of  [jneumococci  was  obtained  from  tliis  fluid. 


FEVERS 


437 


Discussion. — Obviously,  this  child's  illness  began  with  a  pneu- 
monia, continued  with  a  double  otitis  media,  and  ended  with  an 
empyema.  The  case  is  introduced  mainly  in  order  to  call  attention  to 
the  very  typical  chart,  which  exhibits,  between  the  thirteenth  and 
twenty-fourth,  the  variations  which  used  to  be  interpreted  as  an  un- 
resolved pneumonia,  but  which  of  late  years  have  been  shown  to  Ijc 
])ractically  always  associated  with  a  de\'elopment  of  a  postpneumonic 
emjjyema. 

The  diagnosis  of  unresolved  pneumonia  was  made  at  the  Massa- 
chusetts General  Hospital:  ii  times  from  1900  to  1905,  5  times  from 
1905  to  Oct.,  1909. 

I  feel  quite  convinced  that  the  cases  which  I  used  to  designate  as 
"  unresolved  pneumonia "  were  all,  or  practically  all,  mistakes,  the 
actual  lesion  being  postpneumonic  empyema. 

Outcome. — The  chest  was  opened  on  the  twenty-seventh  and  a 
large  amount  of  pus  evacuated,  after  which  the  temperature  promptly 
fell  to  normal.  The  discharge  ceased  in  three  weeks.  The  week  after 
this  the  wound  was  healed  and  the  child  went  home  well. 

Diagnosis. — Pneumonia  and  general  pneumococcus  infection. 

Case  231 

A  laborer  of  twenty-four  entered  the  hos])ital  April  25,  1908.  In 
June,  1907,  he  had  had  rheumatism  for  a  week.  Two  weeks  before 
the  ])rescnt  illness  he  had  had  a  bad  sore  throat.  Ten  days  ago  he 
began  to  have  tenderness  and  pain  in  both  knees  and  ankles,  which 
compelled  him  to  go  to  bed.  Later,  his  hands,  li]js  and  shoulders 
became  affected,  the  jxiin  preventing  slcc]).  During  the  ]jast  week  he 
has  had  four  nosebleeds. 

Physical  examination  showed  that  the  tonsils  were  large  and  soft, 
but  not  red.  Cardiac  impulse  extended  to  the  fifth  space,  but  did  not 
y)ass  the  nijjple.  There  was  no  enlargement  to  the  right.  The  first 
sound  was  replaced  l)y  a  murmur.  The  pulmonic  second  sound  was 
reduplicated.  The  murmur  was  also  heard  in  the  axilla.  Lungs  and 
alxlomen  showed  nothing  almormal. 

The  joints  of  l)oth  hands,  wrists,  and  the  right  knee  and  both  ankles 
were  sv^•ollen,  hot,  slightly  reddened,  and  tender. 

White  cells  were  t 6.600. 

The  course  of  the  tem])erature  is  seen  in  the  accompanying  cliart 
(Fig.  96). 

On  the  second  of  Ahiy,  under  strontium  salicylate,  lo  grains  e\ery 
hour,  the  patient  seemed  almost  well,  and  was  about  ready  to  go  home 


438 


DIFFERENTIAL    DIAGNOSIS 


when  a  loud  friction-rub,  roughly  synchronous  with  the  heart's  action, 
was  heard  along  the  left  edge  of  the  sternum,  on  the  level  of  the  fourth 
and  fifth  rib.  There  was  no  pain  and  no  fever.  The  white  cells  were 
1 1, coo.  The  friction-rub  persisted  for  two  weeks,  but  was  never  accom- 
panied by  any  pain. 

On  the  eighth  of  May  he  began  to  have  considerable  dyspnea,  and 
crackling  rales  appeared  at  the  right  apex,  in  front,  and  throughout 
the  whole  left  lung.  He  became  rather  cyanotic.  His  white  cells  rose 
to  29,000, 

On  the  ninth  pain  appeared  in  the  right  upper  quadrant  of  the 
abdomen,  together  with  rigidity  and  slight  distention.  Nothing  could 
be  made  out  on  palpation. 


=i=ig!j,_i?jL 


Fig.  96. — Chart  of  case  231. 


On  the  eighteenth  of  ]\Iay  the  leukocytes  were  still  29,000.  The 
patient  was  up  in  a  chair  a  good  deal  of  the  time,  and  fairly  comfortable, 
but  slept  little  and  did  not  seem  to  gain  strength.  The  abdominal 
distention  was  very  obstinate  and  difficult  to  overcome.  His  hands  and 
feet  began  about  this  time  to  show  considerable  edema.  From  the 
twentieth  of  ^lay  he  gained  steadily,  although  his  white  cells  remained 
high,  and  on  the  twenty-ninth  of  ]May  were  still  24,000. 

On  the  eighth  of  June  his  lungs  were  clear,  the  heart  showed  the 
murmur  previously  described,  but  no  pericarditis. 

On  the  twelfth  of  June  he  had  a  second  attack  of  sore  throat.  On 
the  nineteenth  his  tonsils  were  removed,  following  which  a  whitish  mem- 
brane formed  over  the  stump.  Xevertheless,  he  continued  to  imjjrove, 
and  on  the  twentv-fourth  was  discharged  well. 


FEVERS 


439 


Discussion. — The  sequence  of  events  here  may  be  summarized  as 
follows:  After  a  previous  attack  of  acute  arthritis  the  present  illness 
begins  with  tonsillitis,  which  leads  immediately  to  a  second  attack  of 
arthritis  associated  with  an  equivocal  cardiac  murmur  which  may  or 
may  not  be  due  to  endocarditis.  In  ]\Iay  he  develops  a  friction-rub, 
due,  presumably,  to  pericardial  exudate.  Later  we  have  edema  of  the 
lungs  and  cyanosis,  due  in  all  probability  to  an  invasion  of  the  myo- 
cardium by  the  same  infectious  agent  which  has  already  attacked  the 
pericardium,  and  perhaps  the  endocardium  (pancarditis).  The  ab- 
dominal symptoms  lead  us  to  conjecture  that  the  gall-bladder  may  have 
become  infected,  or  that  a  mild  degree  of  peritonitis — such  as  often 
occurs  as  part  of  a  general  sepsis — may  also  be  present.  Finally,  the 
illness  winds  up  with  a  second  attack  of  sore  throat. 

We  have  here  an  excellent  example  of  a  sei)tic  infection  due  to  some 
unknown  but  presumably  attenuated  type  of  pyogenic  organism.  One 
structure  after  another  is  attacked,  yet  the  patient's  resistance  is  such 
that  he  overcomes  the  invasion  again  and  again,  and  may  be  left  in 
the  end  nearly  or  quite  as  strong  as  he  was  in  the  beginning.  In  case  he 
overcomes  altogether  this  present  attack,  the  chief  danger  is  that  the 
myocardium  or  the  kidney  will  be  permanently  scarred,  so  that  in 
later  life  a  "chronic"  myocarditis  or  nephritis  will  appear  apparently 
out  of  a  clear  sk}-.  In  practice  we  often  see  this  second  chapter  without 
the  first,  as  the  infection  has  been  passed  through  without  being  desig- 
nated as  anything  more  important  than  "the  grip"  or  "a  common  cold." 

Diagnosis. — Sepsis. 

Case  232 

A  stableman  sixty-two  years  old  entered  the  hos])ital  February  lo, 
IQ08.  He  has  always  Ijcen  well.  He  denies  venereal  disease.  His 
habits  are  good.  For  the  past  four  or  five  days  he  has  noticed  fever 
and  severe  cough,  with  yellow  sputa.  This  morning  he  began  to  have 
severe  i)ain  in  the  lower  right  chest,  associated  with  shortness  of  breath, 
Init  was  al)le  to  walk  to  the  hos])ilal.  The  course  of  his  tcm})eraturc 
is  seen  in  the  accom])an}ing  chart. 

Phvsica"!  examination  showed  sHght  cyanosis;  ra])id.  labored  breath- 
ing; the  right  ])U])il  larger  than  the  left,  and  reacting  sluggishly  to  light. 
The  tongue  came  out  somewhat  to  the  right.  There  was  well-marked 
Riggs' disease.  The  heart's  a] )ex  extended  r;]  inches  outside  the  nipi'lc 
line  in  the  fifth  space;  the  right  l)or(ler  of  dulness  not  made  out;  the 
heart  was  otherwise  negative.  The  right  lung  was  dull  below  the 
ni])ple  line  in  the  front  and  axilla,  and  up  to  a  corresponding  ])()int  in 


440 


DIFFERENTIAL   DIAGNOSIS 


the  back.  Tactile  and  vocal  fremitus  were  diminished.  Breathing  was 
bronchial,  especially  near  the  upper  border  of  dulness.  Many  fine 
crackles  were  heard  throughout  both  chests. 

The  liver  and  other  abdominal  viscera  were  normal,  though  the  belly- 
wall  was  held  rather  rigid. 

The  sputa  was  mucopurulent.  It  contained  no  tubercle  bacilli 
and  very  few  pneumococci. 

The  patient  did  not  seem  very  sick,  but  was  slightly  delirious  at 
night. 

On  February  i6th  the  physical  signs  and  temperature  were  un- 
changed.    The  patient  was  alert,  active,  and  did  not  seem  to  feel  sick. 


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Fig.  97. — Chart  of  case  232. 


X-ray  showed  no  evidence  of  pleural  effusion.  The  sputa,  repeatedly 
examined,  showed  nothing  abnormal. 

On  March  8th  he  was  sitting  up,  but  there  was  no  change  in  the 
physical  signs. 

On  March  30th  the  dulness  is  perhaps  a  little  less.  There  are  no 
rales.     He  feels  quite  well,  has  no  cough,  and  is  discharged. 

Leukocytes:  February  nth,  17,800;  February  14th,  19,400;  February 
i6th,  27,400;  February  i8th,  15,700;  February  20th,  13,900;  February 
22d,  31,100;  February  25th,  14,700;  February  29th,  24,200;  March 
4th,  16,300;    March  7th,  10,900;   March  nth,  11,400. 

Discussion. — This  case  is  introduced  chiefly  on  account  of  the  re- 
markable temperature  chart  and  the  equivocal  signs  in  the  chest.     The 


FEVERS 


441 


rapid,  labored  respiration,  the  cyanosis,  the  bronchial  breathing,  and 
the  high  initial  fever  are  strongly  suggestive  of  pneumonia,  but  it  is 
very  unusual  to  find  the  vocal  and  tactile  fremitus  diminished  <)\er 
pneumonic  solidification. 

The  long  duration  of  the  fever,  the  absence  of  any  rusty  sputa,  the 
moderate  constitutional  symptoms,  and  the  signs  at  the  base  of  the 
lung  are  very  characteristic  of  a  pleural  effusion,  serous  or  purulent; 
yet  the  A'-ray,  which  usually  shows  a  shadow  corresponding  to  such 
an  exudate,  was  negati\'e  at  the  time  when  the  physical  signs  were 
exactly  as  above  described.  In  \iew  of  the  outcome  of  the  case  I  do 
not  see  how  we  can  make  any  other  diagnosis  than  pleuris}',  and  in 
view  of  the  negative  v-ray  examination  it  seems  quite  possible  that  we 
are  dealing  with  a  plastic  exudate  resulting  finally  in  thickening  from 
scar  formation. 

Diagnosis. — Pleural  effusion. 


Case  233 

A  child  of  fi\-e  entered  the  hospital  May  20,  1908.  His  father  had 
just  had  typhoid  fever  and  his  mother  ])neumonia.  They  are  both  at 
the  Massachusetts  Hospital.  One 
sister  is  now  ha\'ing  measles  at 
the  City  Hospital.  The  child 
was  ])erfectly  well  until  last  night, 
when  he  became  feverish,  lost 
his  ap])etile,  and  at  nine  o'clock 
vomited.  Since  then  he  has  been 
drowsy,  with  slight  cough,  and  has 
\omited  several  times  more.  He 
comy)lains  of  no  ])ain  anywhere. 

The  course  of  the  tempera- 
ture as  seen  in  the  accompany- 
ing cliart  (Fig.  98). 

Pliysical  examination  showed 
head,  chest,  and  abdomen  nega- 
li\c.  There  was  no  rigidity  of 
the  neck;  no  Kernig's  sign. 
There  were  many  small  red  spots 
scattered  over  the  trunk  and  limbs, 
not  disappearing  on  ])ressure. 

The  wliite  cells  were  51,000,  with  88  ])er  cent,  polynuelear. 

Ne<'ati\e  urine. 


442 


DIFFERENTIAL   DIAGNOSIS 


After  entrance  the  child  was  drowsy  and  continued  to  vomit  fre- 
quently and  with  great  suddenness.  On  the  twenty-first  he  became 
slightly  delirious. 

Discussion. — In  view  of  the  other  cases  of  fever  in  the  family,  one 
would  naturally  conjecture  that  this  child  has  contracted  either  typhoid, 
measles,  or  pneumonia.  The  eruption  is  apparently  hemorrhagic, 
not  macular  or  ])a])ular,  and  this,  with  the  absence  of  coryza,  conjuncti- 
vitis, and  Koplik's  s])ots,  is  sufficient  to  exclude  measles  even  at  the 
outset,  before  the  long  course  of  the  fever  had  shown  us  that  some  more 
serious  infection  must  be  at  work. 

Typhoid  may  be  unconditionally  excluded  by  the  presence  of  a  high 
and  continued  leukocytosis. 

Of  pneumonia  there  are  no  signs,  though  the  herpes,  the  fever 
and  leukocytosis  suggest  it.  In  children  pneumonia  is  almost  never 
"central,"  perhaps  because  it  is  easier  to  reach  the  depths  of  their  lungs 
by  the  ordinary  methods  of  physical  examination. 

The  vomiting  and  sluggishness,  as  well  as  the  sudden  onset,  are 
rather  characteristic  of  meningitis,  but  against  this  is  the  normal  flexi- 
bility of  the  neck,  the  absence  of  any  ham-string  contractions  and  of 
any  complaint  of  headache — all  very  constant  symptoms.  No  further 
certainty  can  be  arrived  at  without  lumbar  puncture. 

In  all  doubtful  fe\'ers  occurring  in  young  cliildren  one  should  in- 
vestigate the  ear-drums,  and,  especially  in  girl  babies,  the  urine,  with 
reference  to  presence  of  pus  and  bacteria.  In  the  present  case  the 
latter  examination  was  made,  not  the  former.  We  were  thrown  off 
our  guard  because  the  child  did  not  complain  of  its  ears,  nor,  indeed, 
of  any  pain,  and  because  there  was  no  discharge. 

Outcome. — Not  until  May  2 2d  was  there  any  evidence  of  rigidity 
in  the  neck.  In  the  afternoon  of  the  twenty-second  lumbar  puncture 
was  done  and  20  c.c.  of  turbid  fluid  obtained.  In  the  sediment  of  this 
fluid  92  per  cent,  of  ])olynuclear  cells  were  found,  and  many  Gram- 
negative  diplococci  were  seen  within  and  without  the  cells.  Flexner's 
serum  was  injected,  and  the  boy  seemed  brighter  next  day;  but  Kemig's 
sign  was  ])rcsent  on  both  sides,  and  slight  internal  strabismus  had 
ap])cared. 

Her])es  appeared  upon  the  li])s  on  the  twenty-fourth.  On  the 
twenty-sixth  he  was  taking  nourishment  freely,  and  wanted  to  sit  u])  and 
go  home.  The  neck  was  less  rigid  and  strabismus  gone;  the  })ulse 
was  of  excellent  quality,  though  rapid. 

The  white  count.  May  23d,  was  42,000;  on  the  twenty-sixth,  21,000; 
on  the  twenty-eighth,  39,000. 


FEVERS 


443 


Lumbar  puncture  was  done  seven  times  more  in  the  course  of  the 
next  three  weeks,  and  Flexner's  serum  repeatedly  injected.  The  amount 
of  fluid  obtained  was  usually  large — 35  to  40  c.c. 

The  patient  seemed  to  be  doing  well  until  the  eighth  of  June,  when 
be  became  rapidly  worse  and  died.  Autopsy  showed  meningitis,  double 
otitis  media,  and  a  very  large  thymus. 

Diagnosis. — Epidemic  meningitis. 

Case  234 

A  child  of  six  entered  the  hospital  August  2,  1907.  He  has  always 
been  well  until  nine  days  ago,  when  he  woke  near  midnight,  feverish 
and  vomiting.  Five  days  ago  his  temperature  was  found  to  be  104°  F. 
Four  days  ago  it  was  103°  F.  In  the  middle  of  the  day  he  had  less  fe\er 
than  at  night.  The  last  two  nights  he  has  slept  fairly  well.  Before 
that  he  was  rather  restless.  All  the  time  his  appetite  has  been  good, 
but  he  has  had  only  liquids.  His  bowels  have  been 
moved  by  cathartics  and  since  the  first  he  has  had 
no  vomiting,  no  nosebleed,  no  pain.  He  has  lost 
considerably  in  weight. 

The  course  of  the  temperature  as  seen  in  the 
accompanying  chart  (Fig.  98). 

Physical  examination  was  entirely  negative; 
urine,  normal.  White  cells,  15,000.  No  Widal 
reaction. 

By  the  eighth  of  August  his  temperature  was 
normal  and  the  child  seemed  perfectly  well.  The 
treatment  consisted  of  laxatives  and  alcohol  sponges. 

Discussion. — All  general  practitioners  see  many 
cases  like  the  above.  Ordinarily,  they  are  spoken 
of  as  "grip"  if  they  occur  in  winter,  and  as 
"indigestion"  or  "])tomain  poisoning"  if  they 
occur  in  summer.  Both  these  usages  seem  to  me 
unfortunate,  in  that  they  tend  to  delay  the  ])rog- 
ress  of  medical  knowledge.  In  the  \'ast  majority 
of  cases  there  is  not  the  slightest  scientific  warrant  for  either  diagnosis. 
The  bacteriologic  or  chemical  evidence  on  which  alone  sucli  diagnoses 
could  be  based  is  ])raclically  never  secured,  and  the  terms  arc  used 
mainly  to  satisfy  the  family. 

It  seems  to  me  much  wiser,  as  well  as  more  truthful,  to  state  that 
in  such  a  case  we  are  dealing  with  an  unknown  infectious  disease.  (See 
]).  405.)     Ptomain  poisoning  is  just  now  a  \ery  fashionable  diagnosis, 


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444 


DIFFERENTIAL   DIAGNOSIS 


and  a  phrase  which  the  laity  loves  to  brandish  about.  People  are  quite 
proud  to  have  suffered  from  such  an  illness.  But  all  this  does  not 
advance  the  progress  of  medicine,  and  tends  in  the  long  run  to  discredit 
our  profession. 

I  have  seen  similar  iexevs  in  which  a  A\'idal  reaction  was  obtained, 
and  to  which,  therefore,  the  term  "abortive  typhoid"  was  quite  justifia- 
bly applied.  If  there  is  a  pharyngitis,  a  tonsillitis,  or  a  bronchitis,  an 
inflammation  of  the  frontal  sinus,  a  jaundice,  or  a  diarrhea,  an  infec- 
tion of  the  urinary  passages  or  a  subcutaneous  abscess  at  any  point, 
the  fever  may  properly  be  considered  as  a  manifestation  of  one  of  these 
local  disturbances.  In  the  absence  of  such  it  should,  I  think,  be  made 
clear  primarily  to  ourselves  and  also  to  our  patients  that  the  disease 
has  at  present  no  name,  and  cannot  be  identified  with  any  trouble 
pre^"iously  knov/n. 

Diagnosis. — Unknown  infection. 


Case  235 

A  school-boy  of  fourteen  entered  the  hospital  December  15,  1907. 
He  has  always  pre\'iously  been  well.  Four  days  ago  he  began  to  have 
pain  in  the  right  lower  quadrant;  it  was  not  very 
severe,  but  has  persisted  to  the  present  time.  He 
vomited  once  the  first  day  and  twice  the  second  day; 
he  has  been  fe\'erish  throughout.  He  has  had  no  cough, 
no  sore  throat  and  no  pain  except  as  above  described. 
The  bowels  have  moved  every  day.  He  was  sent  into 
the  hospital  with  a  diagnosis  of  appendicitis.  At  en- 
trance, there  was  slight  tenderness  in  the  right  iliac 
fossa,  but  ^^•ithout  any  spasm. 

Rectal    examination    was    negative;    white   count, 
20,000;  Widal  reaction  negative. 

During  the  night   the  patient  became  slightly  de- 
lirious and  the  temperature  rose  to  106.2°  F, 

Physical  examination  showed  at  the  right  base  slight 
dulness,  slightly  diminished  tactile,  slightly  increased 
vocal,  fremitus,  and  a  few  moist  rales.  Chest  and 
abdomen  were  otherwise  negative.  The  right  knee- 
jerk  could  not  be  obtained;  the  left  could  be  obtained 
only  with  difficulty. 
The  patient  was  very  delirious,  quarreling  with  imaginary  persons, 
and  reaching  out  for  objects  in  the  air.    There  was  no  stiffness  of  the 


u ! 


Fig.    100.  —  Chart 
of  case  235. 


FEVERS  445 

neck,  no  Kernig's  sign.  The  pupils  have  Ijeen  markedly  dilated  through- 
out, but  have  been  equal  and  reacted  well  to  light. 

Discussion. — What  infectious  diseases  are  most  common  in  boys 
of  this  age? 

(i)  Pyogenic  sepsis,  with  or  without  a  focus  in  bone,  joint,  or  heart 
valve. 

(2)  Pneumococcous  infections,  with  or  without  a  demonstrable 
pneumonia. 

(3)  Meningitis  (otitic,  epidemic,  or  tuberculous). 

(4)  Typhoid. 

(5)  Appendicitis. 

(6)  Unknown  infections. 

The  latter  are  perhaps  the  commonest  of  all. 

Though  the  pain  is  referred  to  the  right  iliac  fossa,  the  presence 
of  a  temperature  of  106°  F.  and  of  an  active  delirium  is  distinctly 
against  apj)endicitis.  We  are  on  our  guard  also  against  the  mistake, 
so  common  in  patients  of  this  age,  of  o\erlooking  a  pneumonia  or  a 
pleurisy  because  the  abdominal  pain  often  associated  with  these  infec- 
tions in  children  occupies  so  prominent  a  place  in  the  clinical  ])icture. 

JNIeningitis  might  begin  in  this  \vay,  and  the  delirium  and  the  absence 
of  knee -jerks,  together  with  the  \"ery  high  fever  and  leukocytosis,  are 
quite  consistent  with  that  diagnosis.  We  are  surprised,  howcxcr, 
whenever  we  find  meningitis  without  stiffness  of  the  neck  or  Kcrni'^'s 
sign,  especial!}'  if  the  patient  is  fourteen  or  yoimger,  for  these  nervous 
manifestations  are  much  more  apt  to  be  early  and  well  marked  in  tlie 
fevers  of  children  than  in  those  of  adults.  K\cn  meningeal  irritation 
without  actual  meningitis  often  makes  a  child  assume  the  j)osture  of 
meningitis.  The  al^sence  of  headache,  herpes,  and  eye  changes  is 
also  somewhat  against  meningitis.  Xe\"ertheless,  this  disease  can  be 
ruled  out  only  in  case  lumbar  puncture  shows  no  e\idence  of  infection. 

A  general  septicemia,  associated  eitlier  with  a  pneumococcus  or  one 
of  the  \-arieties  of  stre])tococcus,  is  the  next  most  reasonable  h}-i)()thesis. 
Without  l)lood  culture  one  cannot  get  any  greater  certainty  in  this 
direction,  but  the  signs  in  the  lung,  though  in  themsehes  slight,  are 
sufTicient  to  incline  us  toward  a  belief  tliat  a  imeuuKKoccous  infeclinr 
is  ])resent.  It  seems  now  to  ])e  quite  clear  that  the  existence  or  the 
degree  of  lung  consolidation  is  quite  a  secondary  and  accidental  nuitter 
in  infections  due  to  the  pneumococcus.  We  are  dealing  in  all  i.ast> 
prol)ably  with  a  general  infection  carried  by  the  bhxxl.  In  the  hmg  it 
may  arouse  no  special  reaction,  may  jn-oduee  a  sliglit  broncb.itis  or 
bronclio])neum()nia,  or  may  bring  about  the  solidillcatinn  of  an  entire 


446 


DIFFERENTIAL   DIAGNOSIS 


lobe.  But  if  all  the  pneumococcous  infections  were  recognized  and 
classified,  we  should  probably  find  that  those  attended  by  a  frank 
pneumonia  are  in  the  majority. 

Outcome. — The  blood  showed  a  pure  culture  of  pneumococci.  By 
the  nineteenth  signs  of  solidification  were  obvious  at  the  right  base. 
Lumbar  puncture  showed  nothing.  The  child  died  on  the  same  day 
on  which  solidification  became  obvious. 

Diagnosis. — Pneumonia. 

Case  236 

A  carpenter  of  thirty-nine  entered  the  hospital  January  i8,  1907. 
His  family  history  is  good.  For  the  last  three  or  four  years  he  has 
had  considerable  cough  in  the  morning,  with  greenish  sputa.  He 
denies  venereal  disease.  He  takes  a  pint  of  whisky  three  times  a  week. 
Three  days  ago  he  began  to  be  chilly,  stopped  work  and  went  to  bed. 
Two  days  ago  he  began  to  have  pain  in  the  region  of  the  heart  and  in 

the  right  axilla.  To-day  he  has 
been  spitting  up  reddish,  frothy  ma- 
terial. His  cough  has  not  kept  him 
awake  at  night.  The  course  of  his 
temperature  is  seen  in  the  accom- 
panying chart. 

Physical  examination  showed 
cyanosis,  a  negative  heart,  thick- 
ened arterial  \Aalls,  many  coarse 
and  medium  bubbles  and  squeaks 
throughout  both  lungs,  diminished 
resonance  in  the  lower  right  back 
and  axilla.  The  upper  part  of  the 
right  front  was  hyperresonant,  the 
lower  part  somewhat  dull,  with 
much-diminished  breath-sounds  and 
\'oice-sounds  over  the  area  between 
the  third  and  fifth  ribs.  Abdomen 
negative. 

0\'cr  both  lower  legs  there  were  many  patches  of  brownish  pigment 
from  the  size  of  a  nickel  to  that  of  the  palm  of  the  hand;  over  the  shins 
there  were  three  white  scars,  two  inches  long,  Vinch  wide,  surrounded  by 
brownish  j)igmentati()n.  The  sputum  showed  a  great  variety  of  bacteria, 
but  nothing  of  s])ecial  im])ortance.  Leukocytes,  25,300,  with  94  per 
cent,  of  polynuclear  cells. 


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FEVERS  447 

On  the  twenty-third,  as  noted,  the  temperature  remained  high,  the 
pulse  irregular;  the  patient  was  cyanotic  and  \ery  noisy.  The  physical 
signs  remained  as  before.     The  sputum  was  constantly  blood-stained. 

Discussion. — There  is  no  way  in  which  we  can  make  alcohol  re- 
sponsible for  the  present  fever.  Some  cases  of  delirium  tremens  are 
febrile,  but  we  have  neither  tremor  nor,  at  the  start,  any  delirium,  and 
there  has  been  no  special  accumulation  nor  increase  of  alcohol. 

The  syphilitic  infection  suggested  by  the  scars  on  the  leg  has  nothing 
to  support  it  in  the  rest  of  the  clinical  picture. 

Though  the  signs  in  the  lungs  are  by  no  means  typical  of  pneumonia, 
there  seems  sufficient  reason  to  take  as  a  working  hypothesis  the  disease 
which  used  to  be  called  "  central  pneumonia."  The  postmortem  evidence 
seems  to  be  insufficient  to  justify  the  belief  that  in  any  considerable 
number  of  cases  solidification  actually  begins  in  and  remains  for  a  time 
confined  to  the  central  portion  of  the  lung.  The  conception  of  "central 
pneumonia"  is  derived,  I  think,  mostly  from  "hind-sight"  in  cases 
characterized  first  by  the  symptoms,  and  only  later  by  the  physical 
signs  of  pneumonia. 

It  seems  to  me  more  reasonable  to  su])pose  that  in  most  of  the  cases 
usually  designated  as  "  central  pneumonia  "  we  arc  dealing,  in  fact,  with  a 
general  pneumococcous  infection  which  produces  in  the  lung  no  lesions 
whate\-er  or  only  a  moderately  severe  bronchitis.  When  a  crisis  occurs 
in  such  a  case  and  the  temperature  falls  suddenly  to  normal,  we  are 
very  apt  to  argue  that  this  proves  the  case  to  ha\-e  been  one  of  loljar 
pneumonia.  I  believe,  however,  that  the  familiar  crisis  is  character- 
istic of  the  pneumococcous  infection  itself,  whether  or  not  it  is  localized, 
for  it  is  a  very  familiar  observation  that  the  signs  of  solidification  are 
often  unchanged  for  many  hours  after  the  occurrence  of  the  crisis.  It 
has  long  been  recognized  that  the  dyspnea  and  cyanosis  which  cease 
so  suddenly  with  the  crisis,  even  though  the  lung  signs  remain  the  same, 
must  be  due  not  to  the  lack  of  lung  space  for  aeration,  but  to  general 
toxemia.     I1ie  same  is  true,  I  beliexe,  both  of  the  fe\cr  and  of  tlie  crisis. 

Outcome. — (^n  tlie  twenty-seventh  the  patient  was  much  heller. 
On  the  third  of  February  he  was  up  and  about  the  ward,  and  on  the 
sixth  he  went  home  well. 

Diagnosis. — Pneumococcous  infeclion. 

Case  237 

A  sclK)ol-l)oy  six  years  old  was  seen  Deceml)er  14.  i()of):  he  had 
ne\er  been  ill  prexiouslv.  He  has  not  been  well  for  the  (ia\s.  i-oniplain- 
ing  of  pain  in  liis  le^s  and  abdomen.     The  (loct(M-  said  it  was  aniiendi- 


448 


DIFFERENTIAL    DIAGNOSIS 


citis.  His  bowels  have  not  moved  for  four  days.  To-day  his  parents 
noticed  red  blotches  on  his  face  and  body,  which  they  say  he  does  not 
scratch. 

Physical  examination  is  entirely  negati^•e,  except  that  the  whole 
bodv  is  covered  with  red,  discrete  patches  from  the  size  of  a  pea  to  that 
of  a  silver  dollar,  apparently  ele\ated  and  surrounded  by  evidences  of 
scratching. 

The  urine  was  negative. 

The  white  cells  were  25,200  on  the  fourteenth;  24,600  on  the  six- 
teenth;  27,600  on  the  twenty-second;    17,000  on  the  twenty-sixth. 

Widal's  reaction  was  slightly  suggestive,  but  not  positive.  The  coagu- 
lation time  of  the  blood  was  three  and  three-quarters  minutes  with  the 
Brodie- Russell  instrument.     Throughout  his  stay  in  the  hospital  the 

^,„       patient  had  no  other  symptoms  or 
signs. 

He  had  numerous  crops  of  spots 
up  to  the  twenty-second  of  Decem- 
ber. After  that  they  ceased,  and 
after  a  few  days  he  seemed  so  ^^■ell 
that  he  was  discharged  on  the 
second  of  January. 

Discussion. — In  the  absence 
of  all  physical  signs  of  \isceral  dis- 
ease it  seems  reasonable  to  associate 
this  fever  with  the  profuse  crop  of 
urticarial  lesions.  The  most  im- 
portant lesson  from  such  cases  is  the 
recognition  that  the  disease  which 
underlies  urticaria  can,  and  often 
does,  produce  fever.  The  other 
and  less  o]J^•ious  results  of  the  urti- 
carial group  of  lesions  discussed  so  fully  1jy  Osier  in  a  series  of  important 
papers  ^  must  al\\-ays  be  borne  in  mind  when  the  history  of  the  case 
or  the  insjjection  of  the  skin  gi\es  us  any  knowledge  of  what  we  arc 
dealing  with. 

Sym])toms  rcsemljling  appendicitis,  gall-stones,  perforating  peptic 
ulcer,  pneumonia  and  many  milder  affections  of  the  respiratory  and 
gastro-intestinal  tract  may  l^e  produced,  when  wheals  or  edematous 
])atches  appear  in  the  internal  organs  as  well  as  in  the  skin. 
Diagnosis. — Urticarial  fe\er. 

^  Amer.  |i>iir.  Med.  S(i.,  1805,  \i)l.  rx.xwii,  p.  629;  I'rii.  Jour.  DennaioL,  Lon- 
don, Kjoo,  V'l].  .xii  ;   .\iiilt.  J<iur.  Med.  Sci.,  1904,  \i)l.  cliv,  ]>.  i. 


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I'i'j;.  102. — Chart  of  case  237. 


FEVERS 


449 


--Kv 


Case  238 

A  butcher  of  twenty-one  entered  the  hospital  May  24,  1908.  He 
has  never  been  sick  before.  His  habits  are  good.  Since  early  yester- 
day morning  he  has  had  fever,  headache,  sore  throat,  slight  cough  with 
whitish  sputa,  and  se\ere,  deep-seated  pains  all  o\er  his  body.  He 
has  vomited  several  times.  His  bowels  mo\ed  once  this  morning. 
The  course  of  his  temperature  is  seen  in  the  accom- 
panying chart.  His  throat  was  red,  showed  no  exudate 
and  no  swelling.  Physical  examination  was  otherwise 
entirely  negati^•e. 

Discussion. — Some  time  in  the  course  of  his  medical 
experience  every  physician,  confronted  with  a  case  like 
that  here  described,  has  occasion  to  ask  himself  the 
question : 

"Can  a  man  be  as  sick  as  this  and  nothing  wrong 
with  him  but  a  red  throat?"  In  such  cases  we  rack 
our  brains  to  see  what  jjossible  diagnosis  we  have  for- 
gotten. We  examine  the  patient  again  and  again  in 
search  for  some  more  extensi\e  organic  lesion.  But 
if  all  these  efforts  are  \-ain,  we  are  dri\en  in  time  to 
the  conclusion  that  a  ''simple  red  throat"  may  be  a 
pretty  serious  affair.  The  case  here  quoted  is  one  of 
the  milder  type,  but  others  which  begin  just  as  inno- 
cently develop  into  the  most  virulent  type  of  general- 
ized sepsis.  The  conclusion  is  that  so  frequently 
em])hasized  in  these  pages,  viz.,  that  few  "local"  in- 
fections are  really  local  even  from  the  start,  that  they  usually  scr.c  their 
wild  oats  very  widely  he/ore  settling  down,  and  that  this  settling  may 
be  only  temporary. 

Outcome. — The  patient  was  given  half  an  ounce  of  castor  oil, 
followed  by  three  5-grain  doses  of  phenacetin  at  hourly  inter\als,  with 
a  grain  of  caffein  to  each  dose.  In  two  days  he  seemed  to  be  entirely 
well. 

Diagnosis. — Pharyngeal  (and  transj)haryngeal)  infection. 


rig.      103. — Chart 
of  case  238. 


Case  239 

.\  printer  of  eighteen  entered  the  lios])ital  June  i,  iqoS;  Iiis  family 
hi>t()r\'  and  ])ast  history  were  good,  lie  is  a  hcaxy  smoker  of  cigarcL>, 
and  chews  a  good  deal  of  to1)acco  besides.  Nine  days  ago  he  began 
to  lia\e  a  tickhsh  throat,  then  a  cough  and  "cold  in  his  head."  which 


450 


DIFFERENTIAL   DIAGNOSIS 


soon  became  severe  enough  to  make  him  give  up  work.  He  has  been 
"  up  and  down  "  until  two  days  ago,  when  he  took  to  bed  for  good. 
Seven  days  ago  his  right  foot  l^egan  to  be  painful.  Yesterday  he  began 
to  complain  of  pain  in  the  region  of  his  heart,  and  his  breathing  was 
accompanied  by  a  groan.  His  cough,  at  the  same  time,  became  much 
worse,  and  his  fever  higher.  I.ast  night  and  to-day  he  has  been  some- 
what delirious.  He  has  had  no  chill,  no  abdominal  pain,  no  vomiting 
or  diarrhea.  The  course  of  his  temperature  is  seen  in  the  accompanying 
chart  (Fig.  104).  The  white  cells  were  55,700,  with  90  per  cent,  of 
poly  nuclear  cells.  The  urine  showed  a  very  slight  trace  of  albumin,  but 
no  casts.      The  tonsils  were  enlarged  and  the  pharynx  reddened.    The 


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heart-sounds  were  regular,  rapid  and  distant.  There  were  no  murmurs. 
Respiration  was  rapid  and  groaning,  the  nostrils  moving  with  each 
breath.  There  was  slight  dulness  in  the  left  back  below  the  angle 
of  the  scapula,  a  trifling  increase  of  voice-sounds  and  of  tactile  fremitus. 
The  respiration  was  normal.  Over  the  lower  axilla  and  in  the  precordia 
a  very  intense  double  friction  sound  was  heard  synchronous  with  respira- 
tion. 

The  abdomen  and  extremities  were  negative,  except  that  on  the  top 
of  the  right  foot  was  a  swollen,  reddened,  painful  area  the  size  of  a 
dollar.     Movements  of  the  toes  seemed  to  be  painful. 

On  June  3d  the  pleural  rub  had  disaj)peared.     Respiration  seemed 


FEVERS 


451 


to  be  distant  in  the  left  back,  and  there  were  many  coarse  rales  in  the 
lower  right  back.  Cyanosis  was  very  marked.  On  the  fourth  the  right 
border  of  cardiac  dulness  had  moved  to  the  right  at  least  an  inch,  and  a 
pericardial  friction  was  heard  to  the  right  of  the  sternum,  while  pleural 
friction  had  returned  in  the  left  axilla.  There  was  no  definite  evidence 
of  fluid  or  solid  in  the  lungs.  Many  fine  purpuric  spots  developed  on 
the  trunk  and  limbs  during  the  forenoon  of  July  4th. 

Discussion. — In  cases  like  this  we  arc  prone  to  ask  the  muckraker's 
familiar  question:  "Where  did  he  get  it?"  The  illness  is  so  sudden, 
so  severe,  yet  there  is  so  little  to  account  for  it. 

It  appears  that  an  infection  showing  itself  first  as  a  sore  throat  was 
scattered  thence  to  the  joints,  the  pericardium,  the  jjleura  and  the 
subcutaneous  tissues.  In  any  one  of  these  and  in  many  other  places 
a  more  definite  localization  might  have  occurred,  as  is  shown  by  the 
course  of  other  similar  cases.  But  here  apparently  there  was  a  very 
widespread  attack,  not  wholly  successful  (/.  e.,  not  j^roducing  am'  very 
obvious  or  extensive  disease)  in  any  one  locality.  For  some  unknown 
reason  infections  which  do  not  become  " localized^^  ojten  seem  to  he  the 
worst  in  case  they  are  not  oj  the  very  mildest  type.  Those  which  "local- 
ize" make  u})  the  great  middle  class  of  moderately  sc\ere  but  not  fatal 
infections. 

In  all  such  cases  our  diagnosis  must  remain  vague  unless  the  results 
of  blood  culture  are  ])ositive. 

Outcome. — On  the  fourth  of  July  a  l)lood  culture  showed  a  profuse 
growth  of  the  streptococcus  pyogenes.     The  patient  died  next  day. 

Diagnosis. — Streptococcus  sepsis. 

Case  240 

A  Russian  girl  ])al)y,  twenty-three  months  old,  entered  the  hosjjital 
December  13,  1Q07.  She  had  never  been  sick  before;  three  days  ago 
she  l^ecame  slec])y  and  feverish,  with  considerable  dysjmea,  but  no 
cough.  She  has  had  no  a])petite  and  has  vomited  twice.  The  body 
has  been  very  hot,  the  feet  and  hands  cold.  The  1)Owe]s  ha\e  been 
moved  In-  cathartics,  the  stools  ])eing  blackish.  Physical  examination 
of  tlie  chest,  a])domen,  and  extremities  was  entirely  ncgati\e. 

\\'hite  cells,  iS,ooo;  urine,  not  obtained. 

Discussion. — Although   the  history  and   the  ])hysical    examination 
apj)ear    to    ha\e    been    conscientiously    made    in     this    case,    tuo    all 
essential  points  are  omitted.      It    is   because  of  thest-  that    I   introduce 
tlie  case. 

II)   Sick  babies  do  not  complain  of  Xhv'n  ears  (,-\en  when  they  are 


452 


DIFFERENTIAL    DIAGNOSIS 


seriously  diseased.     The  uninitiated  are  apt  to  expect  that  a  baby  with 

otitis  media  will  indicate  in  some  way  that  its  ears  are  painful,  even 

when  it  is  too  young  to  talk,  but  experience 
shows  that  the  baby  rarely  puts  its  hands  to 
its  head  or  gives  any  other  sign  that  it 
knows  what  ails  it. 

(2)  Especially  in  girl  babies  suffering  from 
obscure  fevers  we  should  always  remember 
the  urinary  tract  and  the  possibility  of  in- 
fection, hematogenous  or  ascending.  The 
difficulties  of  collecting  and  examining  the 
urine  of  young  babies  often  lead  to  its  being 
disregarded,  to  the  great  detriment  of  the 
child,  since  most  of  the  milder  urinary  infec- 
tions can  be  cured  in  their  earlier  stages  by 
the  administration  of  urotropin  and  an  abun- 
dance of  water. 

Outcome. — On  the  nineteenth  a  puru- 
lent discharge  was  seen  in  each  ear.  Tem- 
perature, pulse,  and  respiration  promptly  fell 
to    normal    and   remained    so.      The   child 

had  been  fretfiJ  up  to  this  time,  but  after  the  discharge  became  quiet. 

Bv  the  twentv-fourth   the  ears  had  ceased  discharging  and  the  child 

went  home  well. 

Diagnosis. — Otitis  media. 


Fig.  105. — Chan 
240. 


Case  241 

A  school-girl  of  fourteen  with  a  negative  family  history  entered 
the  hospital  March  14,  1907.  She  has  had  measles,  chicken-pox,  and 
whooping-cough.  For  the  last  six  months  she  has  comjjlained  of  frontal 
headache  each  day  after  school.  The  pain  goes  away  by  bed-time.  On 
January  24.  1906,  the  child  had  adenoids  removed,  without  any  improve- 
ment either  in  her  hearing  or  in  her  general  health.  Her  a])petite  has 
been  ])Oor  since  Iter  measles  seven  vears  previously.  Two  months  ago 
she  had  a  discliarge  from  one  ear.  For  a  week  or  two  there  has  been 
tenderness  in  the  sides  of  her  neck  and  under  her  jaws. 

On  February  <Sth  she  began  to  ha^"e  constant  headache,  witli  fe\'er 
and  drowsiness.     These  S}'m])toms  have  continued  e^■er  since. 

On  jjhysical  examination  the  child  looked  sick  and  "toxic,"  the 
suljlingual  gland  large  and  tender,  both  submaxillaries  also  large,  llie 
glands  in  the  axilla,-  and  groin  were  slightly  enlarged.     There  was  a  soft 


FEVERS  453 

systolic  murmur  at  the  apex.  The  heart  was  otherwise  normal,  likewise 
the  lungs  and  abdomen.  There  was  no  tenderness  over  the  mastoids; 
the  white  cells  were  12,400,  65  per  cent,  of  which  were  polynuclear; 
there  was  no  anemia;  the  urine  was  normal,  Widal  reaction  negati\e. 
Her  throat  and  ears  were  carefully  examined,  but  nothing  abnormal 
was  found  there. 

Discussion. — No  doubt  this  girl  has  had  eye-strain  and  presumably 
She  has  had  adenoids  and  otitis  media,  but  there  seems  no  reason  to 
believe  that  the  otitis,  the  adenoids,  or  any  of  her  previous  infections 
are  the  cause  of  the  present  glandular  enlargement. 

The  main  question  is  whether  we  are  to  connect  the  headache,  fe^•er, 
and  other  constitutional  symptoms  with  the  presence  of  these  glands. 
Glandular  fever  is  a  diagnosis  to  be  made  only  when  no  other  causes 
can  be  found  either  for  the  adenitis  or  the  fever. 

Such  an  adenitis  is  common  enough  as  part  of  an  infection  arising 
from  the  mouth  or  throat,  or  as  the  residual  result  of  such.  But  at  the 
present  time  there  seems  to  be  no  source  of  infection  m  the  mouth  or 
throat,  no  bad  teeth,  no  alveolar  abscess,  no  tonsillitis  or  otitis. 

There  is  no  enlargement  of  the  parotid  glands,  no  history  of  exposure 
to  mumps,  and  none  of  the  periglandular  infiltration  usually  seen  in  that 
disease. 

The  glands  may  possibly  be  tuberculous,  but  we  have  no  e^•idence 
of  tiiberculosis  elsewhere,  no  softening  or  sinus  formation,  no  adherence 
to  the  skin  or  surrounding  tissues;  the  sublingual  gland,  moreover,  is 
not  often  involved  in  tuberculosis  unless  as  a  part  of  a  \'cry  extensi\e 
j)rocess. 

Leukemia  can  be  ruled  out  by  the  blood  examination.  Hodgkin's 
disease  rarely  occurs  with  just  this  distribution.  It  cannot,  however, 
l)e  i)ositively  excluded  save  l)y  the  outcome  of  the  case.  The  absence 
of  any  history  or  lesions  of  syphilis  makes  it  reasonal)lc  to  exclude  that 
disease  in  a  girl  of  this  age. 

As  a  result  of  this  reasoning  we  are  left  with  an  unexi)lained  fever 
and  glandular  enlargement.  To  this  combination  of  symptoms,  when 
running  a  rather  short,  self-limited,  and  usually  favorable  course,  the 
name  of  glandular  fever  may  l)e  gi\en. 

Outcome. — By  the  twentv-third  she  was  silling  u])  in  her  chair 
and  ihc  glands  were  much  smaller.  By  tlie  Iwenly  fiftli  she  was  frcr 
from  all  sym|)loms.  The  glands  were  still  palpable,  but  now  wire 
hard  and  free  from  tenderness. 

Diagnosis. — (ilandular  fever  (?). 


454 


DIFFERENTIAL   DIAGNOSIS 


Case  242 


A  factory  hand,  twenty-six  years  old,  entered  the  hospital  February 
22,  1908.  His  family  history  and  past  histor}'  are  negative,  his  habits 
<Tood.  He  has  been  more  constipated  than  usual  for  the  past  four 
months,  the  bowels  moving  once  in  four  or  five  days.  Two  weeks  ago 
he  began  to  have  headache  and  poor  appetite.  Eight  days  ago  he  began 
to  have  steady,  moderate  pain  at  the  costal  margin,  not  referred  else- 
where.    Fi\e  days  ago  he  noticed  that  his  eyes  were  yellow. 

Phvsical  examination  is  negative,  except  for  moderate  jaundice  of  tiie 
skin  and  conjunctivas,  accompanied  by  rigidity  of  the  right  rectus  near 
the  ribs.  There  is  tenderness  and  dulness  on  percussion,  extending 
I  i  inches  below  the  rib  margin  in  the  nipple  line.  The  edge  of  the  spleen 
is  not  felt  at  entrance,  but  on  the  twenty-third  of  Februar}-  it  was  easily 
felt  and  considered  to  be  sharp.  The  mine  contains  bile,  but  is  not 
otherwise  remarkable.  The  stools  are  not  clay  colored.  By  Februar}^ 
26th  the  tenderness  and  spasm  had  disappeared,  but  the  jaundice  was 
still  present  at  the  time  of  his  discharge,  ]March  17th,  although  it  had 
become  ^■ery  much  less  intense. 

The  treatment  consisted  of  20  grains  of  sodium  phosphate  three 
times  a  day,  J  grain  of  calomel  every  fifteen  minutes  for  ten  doses,  fol- 
lowed by  h  ounce  of  magnesium  sulphate.  A  diet  free  from  fat  was  also 
given. 

Discussion. — When  we  have  a  case  of  jaundice  of  short  duration, 
not  following  upon  or  resulting  in  any  other  recognizable  disease  such 
as  gall-stones,  obstructive  cancer,  syphilis  or  cirrhosis  of  the  li\er, 
we  are  apt  to  call  it  catarrhal  jaundice. 

Just  what  this  means  we  do  not  know.  Many  cases  like  the  present 
one  have  a  considerable  degree  of  fever,  many  more  have  jaundice  for 
some  days  preceding  the  onset  of  digestive  symptoms,  so  that  it  seems 
hardly  reasonable  to  suppose  that  a  gastroduodenitis  has  extended  up 
the  bile-duct  and  occluded  it,  according  to  the  classic  conce|)tion  of 
the  disease.  It  seems  more  reasonable  to  believe  that  the  jaundice  is 
one  feature  of  an  infectious  cholangitis  or  some  other  type  of  hemato- 
genous infection. 

Diagnosis. — Catarrhal  jaundice. 

Case  243 

A  housemaid  of  twenty-one  entered  the  hospital  April  30,  1907, 
complaining  of  abdominal  yjain.  Physical  examination  indicated  the 
presence  of  Huid,  and  operation  showed  a  diffuse  tubercular  peritonitis. 


FEVERS 


455 


The  patient  had  fever  for  two  weeks,  after  which  she  became  afebrile 
and  was  transferred  to  the  medical  wards. 

At  both  bases  there  was  diminished  breathing,  fine  rales  and,  on 
the  right  side,  dulness.  The  abdomen  was  of  board-like  rigidity,  with 
shifting  dulness  in  each  flank  and  general  tenderness.  The  patient 
when  received  was  vomiting  everything  taken.  She  was  star\ed  for 
twenty-four  hours  without  relief.  Washing  her  stomach  was  also  of  no 
benefit,  and  many  drugs  were  tried  ineffectually.  Soon  after  the  first 
of  June  the  patient  spontaneously  ceased  vomiting,  began  to  be  more 
comfortable  and  to  take  food.  The  course  of  her  temperature,  mean- 
time, is  seen  in  the  accompanying  chart  (Fig,  io6).     On  the  ninth  of 


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Fig.  io6. — Chart  of  case  243. 


June  slight  dulness  and  prolonged  expiration  were  noticed  at  the  left 
apex  in  front  and  behind.  By  the  fifteenth  she  had  developed  a  left- 
sided  otitis  media,  which  was  pronounced  to  ])e  tubercular  by  the  aural 
consultant,  Dr.  H.  L.  Morse.  On  June  23d,  a  ])urulent  vaginal  discharuc 
and  slight  ])ericardial  friction  were  made  out. 

Discussion. — Tn  the  discussion  of  previous  cases  T  have  rc])eate(lly 
referred  to  the  special  ])oints  of  election  at  which  a  general  infection  i> 
j)rone  to  settle  or  break  out  (joints,  heart,  pleura,  gall-bladder,  jicri 
toneum,  sul)cutaneous  tissues,  kidnc}). 

In  the  present  case  we  ha\e  indications  of  a  similarly  wide  distribu- 
tion of  lesions.     The  ])atient  has  already  been  o])cratc(l  on  for  the  rclii-f 


456 


DIFFERENTIAL   DIAGNOSIS 


of  a  tubercular  peritonitis.  It  seems  reasonable,  therefore,  to  suppose 
that  tuberculosis  is  also  the  infection  at  work  at  the  present  time  in 
various  other  tissues. 

Outcome. — The  patient  died  on  the  twenty-fourth  of  June.  Autopsy 
showed  general  miliary  tuberculosis  and  tubercular  peritonitis,  tuber- 
culosis of  the  tubes,  retroperitoneal  and  mesenteric  lymph-glands, 
tuberculous  ulcers  of  the  rectum.  The  infection  of  the  middle  ear  was 
not  tuberculous,  but  was  of  streptococcous  origin. 

Diagnosis. — Miliary  tuberculosis. 


Case  244 

A  longshoreman,  twenty-one  years  old,  entered  the  hospital  August 
24,  1910.    He  has  been  to  sea  a  good  deal,  especially  to  the  West  Indies, 


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Fig.  107. — Chart  of  case  244. 

but  within  the  past  year  has  not  been  further  south  than  Georgia.  Left 
there  eighteen  days  ago  and  landed  at  Boston  eight  days  ago,  where  he 
at  once  fell  ill,  with  se\cre  pain  in  the  back  and  legs,  which  has  lasted 
ever  since.  FexenVh  and  sleepless.  One  nosebleed.  No  chills.  Diar- 
rhea began  two  days  ago,  Ijut  ceased  yesterday. 

Three  or  four  weeks  ago  he  had  a  boil  on  his  left  hand,  but  it  healed 
promijtly.     A  similar  Ijoii  apj)eared  three  days  ago  on  his  right  hand. 


FEVERS 


457 


Family  history,  past  history,  and  habits  good.  Denies  venereal 
disease. 

Physical  examination  showed  an  abundant  crop  of  rose  spots  on  the 
trunk.  The  axillary  lymph-glands  were  slightly  enlarged.  The  sjjleen 
was  not  felt,  but  seemed  distinctly  enlarged  on  percussion. 

Widal  reaction  positive  (1-50).  White  cells,  10,000,  among  which 
there  were  59  per  cent,  of  polynuclears,  t,^  per  cent,  of  large  lymphocytes, 
7  per  cent,  of  small  lymphocytes,  and  i  per  cent,  of  eosinophiles.  The 
stained  smear  was  otherwise  negative. 

The  urine  averaged  50  ounces  in  twenty-four  hours.  At  entrance  it 
contained  a  large  trace  of  albumin,  and  in  the  sediment  very  numerous 
fine  and  coarse  granular  casts  with  cells,  blood  and  fat  adherent.  A 
week  later  the  albumin  and  casts  disappeared  and  did  not  return.  The 
stools  were  negative. 

The  temperature  is  seen  in  the  accompanying  chart. 

By  August  30th  the  boils  on  his  hand  were  healed,  but  two  more 
appeared  on  the  back.  Culture  from  the  pus  obtained  on  opening  them 
showed  Staphylococcus  aureus. 

Discussion. — Typhoid  seemed  obviously  the  diagnosis,  though  the 
patient  (like  many  other  tyj)hoid  patients)  was  never  "typhoidal,"  /.  c, 
stupid,  in  the  least;  but  Sc]jtember  21st,  as  the  temperature  looked  un- 
characteristic and  showed  no  permanent  trend  either  up  or  down,  we 
tried  another  Widal  test  and  found  it  negati\-e.  This  test  was  again 
negative  on  the  2 2d  and  the  leukocytes  were  found  to  number  10.000. 
The  absence  of  Widal's  test  and  of  leukopenia  at  this  i)eriod  of  the 
disease  seemed  very  suspicious,  also  the  repeatedly  negati\e  Diazo  re- 
action. 

Paratyphoid  (al])ha  and  beta  strains)  was  tested  for  twice,  with  nega- 
tive results.  There  was  a  slightly  suggestive  agglutination  test  with  a 
strain  of  colon  bacilli. 

Tuberculosis  was  next  searched  for,  but  the  lungs,  the  osseous, 
lym])hoid,  and  genital  tissues  were  entirely  negalixc. 

Octoljer  3d  we  tried  von  Pircjuet's  cutaneous  test,  wliich  ])r()\cd 
negative.     Blood-cultures  were  also  negatixe. 

'' Bed  fever"  (a  tcm])eralure  which  disa])pears  wlien  the  patient  get> 
up  and  moves  aljout)  was  tested  for  Ijy  getting  this  ])atienl  out  of  bed. 
but  after  several  days  his  fe\er  was  as  liigh  as  e\er. 

'Py])hoi(l  remained  the  diagnosis,  though  a  most  uiisati-facton'  onr. 

Outcome. — ( )ctol)er  7th  the  blood  was  again  examinrd  for  malaria. 
and  estixo-autumnal  crescents  were  found  in  al)ui'idance.  7"//''  urii^ina! 
blood-smear  of  Auii^ust  2.^t]i  i^as  Ihoi   hunted  up  a)ul  Joum!   lo  contain 


458 


DIFFERENTIAL   DIAGNOSIS 


esiivo- autumnal  (ring-form)  parasites,  which  had  been  o\-erlooked  on  the 
lirst  examination.     The  original  Widal  reaction  remains  unexplained. 

The  absence  of  chills,  the  presence  of  Widal's  reaction,  and  the  false 
report  on  the  blood-smear  are  responsible  for  my  mistake  in  this  case. 

Diagnosis. — Estivo-autumnal  malaria. 

Tablk    XI. — Long  Fevers.     S/'^ns  and  Syvipioms. 


Favoring  cnn- 
Causes.                                 ditions. 

1 

Onset. 
Slow. 

Local  lesions. 

I 

Suggestive 

signs.                       Blood. 

Aug.,  Sept.,  Oct. 

Typhoid  fever Infected  water  or 

j     milk.     Carrier. 

o 

Rose  spots.           Leukopenia. 
Palpable           Widal.     Bacilli 
spleen.           i       by  culture. 

Sepsis      Lowered  vitality. 

Rapid. 
Slow. 

Focus  of  infec- 
tions.    Heart. 

Steep  curves  in  i    j       ,         .     . 
chart.                Leukocytosis. 

Tuberculosis 

Poverty. 
Congestion. 
Contagion. 

Lungs.    Pleura. 
Bones.   Glands. 

Steep  curves  in                Not 

chart.               characteristic. 

Meningitis      

9 

Rapid. 

Nervous 
system. 

Stupor. 

Delirium.            r      i         .     • 
Retracted  head.     L<="kocytosts. 
Spinal  fluid.     1 

influenza    

Contagion. 

Rapid. 

Upper  respira- 
tory tract. 

I}.,  .11;                Rarely  bacilli 
^'''-''"-                 by  culture. 

Infectious  arthriti 


syphilis 


Rapid.  Joints  Joint  lesion  Moderate 

■'  obvious.         1     leukocytosis. 


Slow. 


Spleen.  Glands.  !  Spleen.  Glands.     ,.,  .     .  .. 

i>i      J  Di      J  Characteristic 

Blood.  Blood. 


ci„_,     '    r\c        1,        .•  lumor.  usu- 

biow.       Often  hepatic.  ,,       ,    ■ 

^  any  obvious. 


Contagion.  Slow. 


Often  -^y 

enlarged  liver 
and  spleen. 


assermann 
test. 


Cirrhosis 


AUohoiisni 


,     ..         T  Ascites. 

CI, ...         .-ascites.     Large      t  ii 

•"■low.  ,,         '^        Large  or  small 

nr  small  liver.  ",. 

hver. 


Rapid. 


Lower  urinary 
tract. 


Gonococci  in 

discharge  or 

blood. 


Occasionally 

gonococci  by 

culture. 


Causes  of  Chills 


1.  "  NERVOUSNESS" 


CASES  TOO  MANY  AND  TOO  VAGUELY  ENUMERABLE  FOR  GRAPHIC 


2.  PYOGENIC  SEPSIS 


1       REPRESENTATION. 


3.  PHTHISIS 


4.  PNEUMONIA 


5.  GALL-STONES 


1171 
465 
395 


6.  MALARIA    (IN 

NEW    E  N  G- 
LANDi 

7.  TYPHOID  \ 

(ONSET)  J 


276 


26C 


Many  other  infectious  diseases  at  the  onset. 


4f)0 


CHAPTER  XIV 

CHILLS 

The  rapid  clonic  spasm  of  many  muscles  which  may  be  the  onlv 
mark  of  a  chill  is  not  to  be  clearly  distinguished  from  a  tremor  such 
as  many  normal  persons  are  subject  to  when  excited.  A  subjective  sense 
of  cold  and  an  abnormal  temperature  may  or  may  not  accompany  the 
tremor.  The  chill  accompanying  gall-stone  colic  is  often  seen  without 
pyrexia.  Even  when  the  chill  marks  the  onset  of  an  infectious  disease 
the  temperature  is  not  always  elevated.  Hence  the  distinction  between 
^^  nervous  chilW^  and  those  due  to  infection  is  sometimes  to  be  made 
only  by  the  accompanying  signs  and  by  the  later  develo])ments.  All 
chills  except  those  of  nervous  origin  are  soon  followed  by  fever. 

"Creeping"  chills,  or  chilly  sensations  without  any  defmite  tremor 
or  any  chattering  of  the  teeth,  are  much  commoner  and  less  distincti\e 
than  the  true  or  "shaking"  chill  ("Schiittelfrost"). 

As  a  rule,  when  chills  are  the  evidence  of  infection  they  accompany 
an  abrupt  rather  than  a  gradual  rise  of  temperature.  The  sudden  high 
fevers  of  malaria,  pneumonia,  tonsillitis  and  pyogenic  sepsis  are  more 
often  attended  with  a  chill  than  the  more  gradual  rise  seen  in  typhoid 
or  j)leurisy. 

Among  the  causes  of  chills  are: 

(a)  Pyogenic  Infections.— T\\c^c  are  doubtless  the  commonest. 
Under  this  heading  comes,  in  all  |)robability,  most  of  those  occurring 
in  tuberculosis  fas  a  result  of  secondary  infections)  as  \\ell  as  those  due 
to  appendicitis,  septic  wounds,  renal  and  hepatic  suppurations,  tonsillitis 
vegetative  endocarditis,  phlebitis,  empyema,  and  erysipelas. 

(b)  Malaria  i)robably  ranks  ne.xt,  csi)ecially  in  the  tropical  and 
subtropical  regions. 

(c)  Severe  pain  (as  in  renal  or  l^iliary  colic)  may  lead  to  a  chili  or 
follow  it,  even  when  no  infection  or  fe\cr  is  demonstrable.  In  some 
cases  chill  (or  vomiting)  seems  to  replace  the  colic  as  a  sort  of  e(|uivaknt. 

id)  "  Urethral  chills,''  such  as  often  follow  the  i)assage  of  a  catheter, 
•^ccur  in  persons  who  show  nothing  of  a  nervous  or  hysteric  taint,  yd 
there  may  be  no  fever  with  or  after  them.  Probably  t!ic  j'ain  and 
irritation  are  enough  to  set  the  nervous  system  "on  edge,"  e\en  if  it  be 
ordinarily  stolid. 


462 


DIFFERENTIAL   DIAGNOSIS 


Case  245 

A  baker  of  thirty-eight  entered  the  hospital  February  6,  1908.  His 
family  history,  past  history  and  habits  were  good. 

January  29th  he  had  a  sudden  chill  in  the  evening.  The  next 
morning  he  vomited  his  breakfast.  Since  then  he  has  been  having 
severe  chills  about  twice  a  day  and  has  vomited  a  great  deal.  He 
has  been  lounging  about  the  house,  but  has  not  been  in  bed  during  the 
day-time;  he  has  had  no  cough  and  no  pain. 

On  examination  he  is  found  to  be  splendidly  developed.  His  left 
pupil  is  slightly  irregular,  both  pupils  reacting  somewnat  sluggishly  to 


Fig.  108. — Chart  of  case  245. 


light.  The  heart  is  altogether  negative.  The  lungs  show  slight  dul- 
ness  and  many  crackling  rales  at  the  left  base  behind,  but  no  other  signs. 
White  cells,  17,000.  The  rest  of  the  physical  examination  and  the  urine 
are  normal. 

The  sputa  shows  many  pneumococci,  some  streptococci;  no  tubercle 
bacilli. 

On  the  tenth  there  were  no  new  physical  signs.  The  leukocyte 
count  continued  high — 17,600. 

On  the  twelfth  there  was  distant  but  distinct  bronchial  breathing  at 
the  left  base. 

The  patient  received   190  grains  of  quinin   in  twenty-four  hours, 


CHILLS 


463 


but  continued  to  have  chills.  On  the  fourteenth,  after  a  ven^  severe 
chill  lasting  half  an  hour,  the  rectal  temperature  was  107°  F.  The 
white  cells  had  now  risen  to  23,900,  and  the  patient  continued  to  have 
daily  chills  lasting  from  forty  to  forty-five  minutes,  the  temperature 
reaching  106,5°  F-  ^^ch  time  and  remaining  there  several  hours. 

On  the  sixteenth  exploratory-  puncture  of  the"  chest  was  done  twice, 
the  needle  entering  solid  lung  each  time.  From  the  blood  withdrawn 
by  the  second  tapping  a  smear  was  made  which  showed  many  pneu- 
mococci,  both  within  and  outside  the  leukocytes. 

On  the  twenty-second  of  February  x-tsly  showed  a  ver>-  high  dia- 
phragm on  the  right  side,  and  a  shadow  behind  the  scapula  between  the 


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,„   '^  113  ^  !^  1?  ^  1!  ^!  r^  1^5  ^  ■!  1?  M  lli  ^  ^' ■^^  1!  ly  »Z^  !•  11^  i^  "  M  !^  L!  ^  ^  ii  ^"  ^i  ^  ^  ?1  ^"/^  ^  ^  "111 ._?  1: 

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tz  ^  tt    ^      t    t  X    ^    L^         v-.^    t-v^  ^  7 

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Z  1^         JSJ^l^^Ztl        I        Z           _J     ^^^x^ltip^^          ii'    ^^^^^7 

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?  .  •.      Z    ^         ^'^    \    -^e^Zl^      -,    *^**^         ^^  ■    7    ^*^^***,--^ 

£    i;      ^^t        ^♦V           "^?           ?.     i               J              ^»-^               -  — ►• 

Fig.  109. — Four-hourly  chart  of  case  245. 


fifth  and  seventh  ribs.  Er}'sipelas  de\-eloped  on  the  twentieth  of 
February  and  spread  all  o^•er  the  face. 

Discussion. — When  a  patient  has  two  chills  a  day  and  a  leuko- 
cytosis ranging  from  17,000  to  23,000,  the  administration  of  large  doses 
of  (juinin  is  altogether  unjustifiable.  There  is  no  reasonable  possihilitx" 
of  malaria. 

Pulmonar\'  tuberculosis  often  ])roduces  chills,  which  not  infrc(|ut'ntl\- 
come  as  close  together  as  in  this  case,  and  sometimes  recur  at  exact  I  \' 
the  siime  hour  each  day,  so  that  the  unwar}-  are  led  to  diagnose  malaria 
and  to  wa.stc  time  and  strength  in  attempting  to  sto])  the  chilli  with 
quinin.     The  signs  in  the  lungs  of  this  ])atient  are  not  at  all  character- 


464  DIFFERENTIAL   DIAGNOSIS 

istic  of  phthisis,  and  the  sudden  onset  of  the  symptoms  would  be  quite 
inexpHcable  if  the  chills  were  due  to  that  disease.  Chills  occurring 
in  pulmonar)'  tuberculosis  come  after  the  disease  has  made  its  presence 
evident  for  many  weeks  or  months  previously. 

By  far  the  most  significant  point  in  this  case  is  the  evidence  obtained 
by  A--ray  examination,  which  appears  to  prove  that  the  source  of  the 
chill  lies  in  or  near  the  li\er.  That  this  is  usually  the  source  of  chills 
for  which  no  obvious  cause  can  be  found  is,  I  think,  the  general  experi- 
ence. When  we  have  searched  the  blood,  the  sputa,  the  subcutaneous 
tissues,  the  ears,  and  the  heart  for  a  sejjtic  focus  and  found  none,  it 
usually  turns  out  that  the  source  of  infection  lies  in  septic  thrombosis 
of  the  portal  vein,  in  hepatic  abscess,  single  or  multiple,  or  in  a  sub- 
phrenic abscess. 

We  cannot  be  more  definite  than  this  in  the  present  case. 

Outcome. — On  the  twenty-seventh  a  needle  introduced  through 
the  eighth  right  space  below  the  angle  of  the  scapula  drew  pus.  A  rib 
was  resected  ]March  2d,  and  a  pus-cavity  the  size  of  the  fist  was  drained. 

The  patient  continued  to  have  chills,  and  died  on  the  twenty-sixth. 

Autopsy  showed  multiple  abscesses  of  the  lung  and  of  the  liver. 

Diagnosis. — Hepatic  and  pulmonarv'  abscess. 

Case  246 

A  Swedish  housewife  of  fifty-six,  who  had  passed  the  menopause  six 
years  previously  and  had  been  otherwise  well  all  her  life,  entered  the 
hospital  December  31,  1907.  She  says  that  one  night  last  spring  while 
in  bed,  but  not  asleep,  she  "began  to  feel  queer."  In  a  short  time  she 
was  seen  to  shake  violently  all  over,  complaining  at  the  same  time  of 
headache  and  vertigo.  These  chills  recurred  five  times  during  that 
month.  After  them  she  felt  weak  and  had  abdominal  pain,  extending 
up  through  the  chest  to  the  throat.  During  the  past  summer  she  was 
much  better,  but  three  months  ago  she  went  to  bed  on  account  of  increas- 
ing pain,  weakness  and  chills;  she  has  stayed  there  ever  since. 

Her  most  troublesome  symptoms  are  headache,  vertigo  and  constant 
ringing  in  her  ears.  She  has  a  poor  appetite  and  often  vomits,  though 
the  vomiting  seems  to  have  no  distinct  relation  to  pain  nor  to  the  time 
of  eating.  C)f  late  she  has  a  good  deal  of  dyspnea,  cough,  and  expecto- 
ration, though  the  latter  is  never  bloody.  She  sleeps  poorly,  and  her 
urine  is  scanty.     She  has  lo-^t  about  ten  pounds  in  weight. 

Xev-ertheless,  rchen  examined,  she  was  found  to  be  ratlier  obese. 
Her  lips  were  pale  and  Ijluish;  the  heart's  dulncss  extended  one-half  inch 


CHILLS  465 

outside  the  nipple  line  in  the  fifth  space,  five  inches  to  the  left  of  mid- 
stemum.  A  blowng,  systolic  murmur  was  heard  at  the  apex,  but  was 
not  transmitted  more  than  an  inch  or  two  in  any  direction.  The  pul- 
monic second  was  not  accented.     The  pulse  tension  appeared  normal. 

In  the  right  back,  below  midscapula,  there  was  dulness  without  any 
other  signs.  Throughout  the  left  back  there  were  a  good  many  fine, 
crackling  rales.  Hemoglobin,  80  per  cent.  The  white  cells  were  16,200 
at  entrance;  three  days  later  they  were  12,300.  The  urine  and  the 
stained  blood-smear  were  normal.  Vaginal  examination  was  also 
negative.     The  temperature  was  below  99.5°  F.  throughout. 

Discussion. — In  some  respects  this  case  reminds  us  of  the  previous 
one.  We  have  chills,  associated  with  obscure,  bilateral,  pulmonar\' 
signs.  Just  as  we  were  getting  ready  to  investigate  these  by  means  of 
the  A;-ray  they  cleared  up  entirely;  otherwise  our  diagnosis  might  ha^e 
remained  long  in  doubt,  although  with  chills  lasting  nearly  nine  months 
we  should  feel  pretty  sure  that  more  definite  and  extensi\'e  changes 
would  by  this  time  be  demonstrable  in  the  lungs  were  they  the  source 
of  the  trouble. 

Endocardial  infection  should  always  be  suspected  when  chills  of 
obscure  origin  are  found  to  be  associated  with  a  cardiac  murmur 
and  a  slight  enlargement  of  the  organ,  especially  if,  as  in  the  present 
case,  there  is  a  leukocytosis.  Against  this,  however,  is  the  long  dura- 
tion of  the  symptoms  and  the  obesity  of  the  patient.  A  person  who  has 
had  ulcerative  endocarditis  for  nine  months  is  not  likely  to  be  obese. 
Further,  the  course  of  the  tcm]:)erature  is  altogether  uncharacteristic 
of  a  cardiac  infection,  especially  one  which  would  appear  to  be  of 
long  duration. 

In  view  of  these  facts  and  of  the  nature  of  the  attacks  it  is  fair  to 
suppose  that  they  may  have  been  due  to  some  form  of  '"nerves."  But 
since  the  ])atient  is  well  past  middle  life  it  is  altogether  probal)lc  that 
there  is  some  arteriosclerotic  change  undcrhing  the  nervous  symptoms. 

Outcome. — By  the  fifth  of  January  the  lungs  were  entirely  clear 
and  the  patient  was  able  to  sit  up.  After  that  slie  com])lainc(l  only  of 
])ain  in  the  small  of  tlie  Ixick,  which  was  greatly  relieN'cd  iiy  cross- 
strap]jing  with  adhesi\-e  plaster.     January  i6th  she  went  home  well. 

Diagnosis. — Hysteria  (with  arteriosclerosis?) 

Case  247 

A  housewife  of  thirty-nine,  of  good  family  history  and  |)ast  histon 
entered  the  hos])ital  Xoveml)er  S,  iqo-j.     Slie  got  a  c(^ld  in  the  liead  1\^o 
weeks  ago  and  was  hoar>e  for  a  day  or  two;    she  tlien  beuan  to  cough 


466 


DIFFERENTIAL   DIAGNOSIS 


up  considerable  yellow  sputa.  During  the  whole  illness  (from  two 
weeks  ago  until  yesterday)  she  had  two  chills  every  day  at  irregular 
intervals,  with  shivering,  chattering  of  the  teeth  and  profuse  sweating 
thereafter.  At  ])resent  she  feels  sore  throughout  the  whole  chest, 
especially  beneath  the  lower  half  of  the  breast-bone.  The  course  of 
the  temperature  is  seen  in  the  accompanying  chart. 

Physical  examination  was  entirely  negative.  The  sputum  showed 
ver}-  large  numbers  of  influenza  bacilli  both  within  and  outside  of  the 
cells.     The  blood  and  urine  were  normal. 

By  the  thirteenth  the  patient  was  im- 
proving slowly  under  laxatives,  heroin  for 
cough  and  bitter  tonics  for  appetite,  but  it 
was  not  till  the  nineteenth  that  she  was 
able  to  go  home  practically  well. 

Discussion. — One  investigates  in  a  case 
like  this  the  ordinar}'  causes  for  multiple 
chills :  concealed  sepsis  with  or  without  endo- 
cardial localization,  malaria,  tuberculosis, 
otitis  media,  li\-er  disease  (including  gall- 
stones), renal  infection,  and  nervousness. 
Since  none  of  these  is  to  be  found,  we  must 
fall  back  upon  the  e\idence  of  an  influenza 
infection,  which  is  the  best  clue  we  have  to 
the  nature  of  the  chills,  although  the  amount 
and  gravity  of  the  infection  seem  dispropor- 
tionately slight  when  compared  with  the 
violence  of  the  constitutional  reaction  mani- 
fested in  the  chills. 
It  is  to  be  remembered  that  the  make-up  of  the  individual, — what 
is  often  called  his  "temperament," — and  especially  his  nervous  system, 
influence  the  degree  and  character  of  the  reaction  against  any  infection, 
such  as  influenza.  Any  shock  or  painful  experience,  such  as  death, 
flood  or  Are,  will  leave  one  person  quite  unmoved,  will  depri\-e  a  second 
of  the  power  of  sleep  and  make  a  third  irritable  and  nen'ous;  in  a 
fourth  it  may  pro\-oke  that  curious  motor  spasm  known  as  a  "nervous 
chill,"  and  in  a  fifth  may  determine  an  actual  con\-ulsion  of  the  type 
ordinarily  called  "hysteric."  All  these  reactions  rejjresent  ditTerences 
in   the  degree  of  sensitiveness  of  the  motor  nervous  system. 

But  there  are  similar  differences  in  the  way  in  which  different  tem- 
[)eraments  react  to  an  attack  from  within — namely,  a  bacterial  invasion. 
Those  whose  motor  res]  )onses  are  excessive  in  the  presence  of  the  ordinary 


Pig.   no.— Chart    of    case 
247. 


CHILLS  467 

annoyances  and  discomforts  of  life  are  apt  to  show  a  similar  exaggeration 
of  the  normal  response  in  their  constitutional  reaction  against  an  infec- 
tious disease.  In  the  present  case  it  \\as  learned  b}-  subse(|uent  ques- 
tioning that  this  woman  had  been  in  the  habit  of  having  chills  whene\er 
any  kind  of  slight  ailment  affected  her.  This  is  perhaps  a  less  common 
idiosyncrasy  than  that  by  reason  of  which  certain  persons,  whom  every 
j)hysician  meets  in  the  course  of  his  practice,  show  a  \-ery  high  tempera- 
ture reaction  when  they  catch  cold  or  have  a  slight  digcsti\-e  upset. 

In  the  discussion  of  some  of  the  jjrevious  cases  I  have  said  that  most 
diagnoses  of  "grip"  or  influenza  seem  unjustified,  because  the  bac- 
teriologic  evidence  is  quite  insufficient.  I  do  not  feci  quite  sure  that 
we  are  right  in  making  the  diagnosis  of  influenza  even  upon  such  e\i- 
dence  as  is  presented  in  the  present  case.  Since  the  epidemic  of  1S89 - 
90  the  influenza  bacillus  has  been  a  regular  inhabitant  of  the  uj^per  air- 
passages  of  practically  the  whole  population  in  New  England.  The 
fact  that  we  find  it  in  the  s])uta  in  connection  with  one  or  another  t}-pe 
of  disease  is,  therefore,  in  itself,  of  little  significance.  When  the  germ 
occurs  in  large  numbers,  both  within  and  outside  the  leukocytes, 
and  when  the  other  varieties  of  organisms  found  arc  in  \er}'  small 
numbers,  it  is  probably  justifiable  to  consider  the  infection  one  of  in- 
fluenza. 

Diagnosis. — Influenza. 

Case  248 

A  chambermaid  of  thirty-eight  was  first  seen  No\"eml)er  6,  1907. 
Two  years  ago  she  was  in  the  Massachusetts  Eye  and  Ear  Infirmarv 
for  nine  days  with  an  acute  inflammation  of  the  left  middle  ear,  which 
was  lanced  sex'cral  times.     Her  hearing  remained  good  afterward. 

Four  days  ago  she  had  a  severe  chill,  followed  by  sweating,  \erti<,'o, 
ringing  and  buzzing  in  both  ears.  The  next  day  there  was  sex  ere  pain 
in  the  left  ear.  Since  that  time  she  has  felt  feverisii,  and  during  the 
last  two  days  has  had  eight  chills  and  has  xomilcd  several  times. 

During  the  last  two  days  she  has  had  a  dull  ache  in  the  left  ear. 
extending  down  her  neck  to  the  left  side  of  [hv  throat.  This  morning 
and  vesterday  morning  slie  went  to  the  V.\v  and  Ear  Inrirniar\\  but  no 
trouble  was  found  with  the  ears.  Throughout  her  i^ne^s  she  has  liad 
insomnia,  anorexia,  and  constipation. 

Physical  examination  showed  an  obese  woman  with  normal  pKj'ils. 
The  heart's  im])ulse  was  felt  with  diflicult}'  in  the  t'ourth  >pa('e,  jii^l 
outside  the  midclavicular  line.  There  were  no  murmur^  or  aicentiui- 
lions.     The  lungs  were  normal.     There  was  some  e]Mga>lric  tendernos, 


468  DIFFERENTIAL   DIAGNOSIS 

but  nothing  else  of  importance  in  the  abdomen.  The  urine  ranged 
between  40  and  60  ounces  in  twenty-four  hours,  the  specific  gravity 
var\'ing  between  1005  and  1023.  Albumin  was  sometimes  absent, 
sometimes  present  in  very  slight  traces.  Casts  were  sometimes  absent, 
sometimes  numerous  and  of  the  hyaline  and  granular  type,  some  of 
them  having  cells  adherent.  In  the  majority  of  the  examinations  it  was 
exceedingly  difficult  to  find  any  casts  at  all. 

The  blood-pressure  at  entrance  was  230.  The  fundus  oculi  was 
normal  on  the  right.  On  the  left  there  was  a  large  area  of  opaque 
nerve-fibers  at  the  lower  edge  of  the  disk. 

Discussion. — The  foreground  of  this  case  consists  of  chills  and  ear 
pains,  the  background  of  various  signs  pointing  toward  a  chronic  ne- 
phritis. The  high  blood-pressure  and  the  ocular  changes  are  especially 
important  in  this  latter  respect.  The  urine  is  equivocal  and  dubious. 
The  condition  of  the  heart  is  not  characteristic,  though  suggestive  of 
slight  enlargement. 

Taking  for  granted  that  there  is  an  underlying  chronic  nephritis, 
what  is  the  cause  of  the  chill?  Otitis  media  is  naturally  our  first  and 
very  decided  suspicion,  but  the  high  character  of  the  work  done  at  the 
Massachusetts  Eye  and  Ear  Infirmary  makes  us  confident  that  we  may 
rely  upon  their  negative  report  regarding  the  ears. 

Nothing  is  said  in  the  text  about  an  examination  of  the  blood  for 
malaria  or  for  leukocytosis,  because  these  examinations  had  not  been 
undertaken  at  the  time  when  I  first  saw  the  case.  They  both  turned 
out,  however,  to  be  negative. 

Knowing  the  proneness  of  all  cases  of  chronic  nephritis  to  an  inva- 
sion by  an  infectious  disease,  it  seems  natural  to  assume  that  some  such 
infection  was  present  in  this  case,  although  we  do  not  find  definite 
evidence  of  its  whereabouts.  There  remains,  however,  one  further 
possibility:  the  chills  may  be  a  direct  result  of  nephritis  without  any 
infection.  Chills  and  convulsions  are  first  cousins.  In  fact,  a  chill 
may  be  described  as  a  generalized  clonic  spasm  of  very  short  excursion. 
In  \iew  of  this  it  seems  more  than  possible  that  the  excessively  high 
blood-]jressure  which  existed  for  a  short  time  in  this  case  may  have 
determined  the  onset  of  chills,  as  we  well  know  that  a  similar  rise  of 
pressure  often  determines  the  onset  of  convulsions.  In  view  of  the  out- 
come of  the  case,  without  further  e\'idence  of  infection,  this  hypothesis 
deser\es  consideration. 

Outcome. — On  the  thirteenth  the  l^lood-pressure  was  still  markedly 
elevated, — 190,—  though  she  had  been  ha\'ing  daily  hot-air  baths  and 
was  j)urged  e\'er}-  second  day  with  an  ounce  of  magnesium  sul])hate. 


CHILLS 


469 


On  the  twent\'-seventh  the  blood-pressure  had  fallen  to  155.  The 
patient  had  no  symptoms  except  slight  tenderness  and  weakness  in  her 
legs.     She  was  then  allowed  to  go  home. 

Diagnosis. — Chronic  glomerulonephritis. 

Case  249 

A  school-boy  of  fifteen,  whose  father  died  of  consumption,  was  first 
seen  April  15,  1908.     He  w^as  always  well  until  two  weeks  ago,  when 
he  began  to  have  headache,  backache,  and  soreness  all  over  his  body. 
Since  then  he  has  had  several  chills,  with  chatter- 
ing teeth.     Yesterday  he  vomited;  throughout  he 
has  slept  well.      There   has   been  no  nosebleed. 
(See  Fig.  iii.) 

When  examined,  the  face  was  flushed,  the 
throat  reddened  and  covered  with  a  mucopurulent 
secretion,  the  glands  in  the  axilke  and  the  right 
epitrochlear  enlarged,  the  neck  not  stiffened.  The 
heart  was  negative  except  for  a  soft,  systolic  mur- 
mur in  the  ]uilmonary  area,  the  lungs  entirely 
negati\"e,  likew  ise  the  abdomen. 

The  white  cells  were  13,400;  Widal  reaction 
negative,  blood  culture  negati\"e. 

Discussion. — Among  the  infections  common 
in  bo}'s  of  liftcen,  which  are  most  often  obscure  ? 

(a)  Endocarditis,  with  or  without  arthritis  or 
chorea. 

(b)  Tuberculosis,  especially  of  the  bone,  glands, 
or  peritoneum. 

(c)  Otitis  media. 

(d)  Brief  febrile  maladies  to  which  no  name  can  be  given  at  ])rcsent, 
and  in  which  no  definite  localization  in  any  organ  is  found  (febricula, 
"gastric  fever,"  "gri])"). 

This  latter  grou])  is  the  most  numerous  of  all. 

The  ])rcscnt  case  seems  to  have  been  investigated  sufiiciently  to  ex- 
clude with  considerable  confidence  any  tuberculous  or  endocardial 
infection.  No  search,  however,  appears  to  ha\'e  been  directed  toward 
excluding  otitis,  a  ])Ossibility  whicli  should  never  l)e  forgotten  in  Aouth 
and  infancy.  In  the  otitis  of  the  adult  our  attention  is  usually  lalled 
at  once  to  a  source  of  the  trouble  by  tiie  occurrence  of  sexire  earache. 

Outcome. — On  the  eighteenth  the  left  ear  began  t()  di-eharge 
and  the  other  followed  suit  soon  at'ter;  \)\  the  twent} -fourth   the  ears 


Fig.  1 1 1 . — Chart  of 
case  249. 


470 


DIFFERENTIAL    DIAGNOSIS 


had  stopped  draining,  and  the  hearing  and  the  boy  seemed  practically 
well.  At  no  time  was  there  any  considerable  amount  of  pain  in  or  near 
the  ears. 

Diagnosis. — Otitis  media. 

Case  250 

A  Russian  clothes-presser  of  twenty-three  was  first  seen  September 
28, 1907.  His  family  history  and  past  history  were  excellent.  He  stated 
that  he  has  nc\-er  been  sick  until  sixteen  days  ago,  when  he  was  seized 
while  at  work  with  a  severe  chill,  followed  by  a  profuse  sweating.  Since 
then  he  has  had  a  slight  chill  twice  a  week.     Occasionally  he  has  sharp 

pain  in  the  right  side  of  the  chest  if 
he  happens  to  take  a  specially  deep 
inspiration. 

When  examined,  the  patient  was 
well  nourished.  (See  Fig.  113.)  The 
glands  in  the  axillae  were  as  large  as 
lima-beans.  There  was  marked  acne 
on  the  back  and  sides  of  the  chest. 
The  heart  showed  nothing  abnormal. 
The  lungs  showed  occasional  scattered 
rales  throughout,  somewhat  more 
numerous  in  the  right  front. 

White^ cells  10,200;  Widal  reaction 
and  stained  smear,  negative. 

Urine,  negative.  The  next  morn- 
ing the  lungs  were  as  in  the  accom- 
panying diagram  (Fig.  114).  The 
pulse  was  rapid  and  dicrotic,  the 
patient  alert  and  anxious.  Each  day 
thereafter  until  October  15th,  the  signs  in  the  lungs  shifted  and  changed, 
rales  coming  and  going,  patches  of  bronchial  breathing  appearing  and 
disa])j)earing. 

Discussion. — Tlie  pliysical  signs  suggesting  possible  causes  for  this 
patient's  chills  are  those  in  the  lym]:)hatic  glands  and  in  the  lungs. 
These  possil)ilities  should  first  be  investigated,  though  we  must  bear  in 
mind  that  some  of  the  other  and  more  obscure  causes  mentioned  in 
pre\'ious  cases  may  be  here  at  work. 

ChilLs  may  be  associated  with  glandular  enlargement  in  lymphoid 
leukemia,  in  Hodgkin's  disease  (with  infection  of  the  glands),  and  in 
glandular    tuberculosis;     occasionally    also    in    syphilis.     Leukemia    is 


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Fig.  112. — Chart  of  case  250. 


Fig.  TT3. — Physical  signs  in  Case  250.     (See  also  Fig.  114.) 


Ing.  T  r-j.^riivsica!  signs  in  Case  250.      Adenitis,  thills,  and  (he>l  pain;    no  cough. 


CHILLS 


471 


here  excluded  by  the  blood  examination.  Hodgkin's  disease  ne\er 
manifests  itself  in  the  axillary  glands  alone,  and  the  siime  is  true  of 
syphilis.  Glandular  tuberculosis  cannot  here  be  excluded,  though  in 
an  adult  it  rarely  causes  such  marked  constitutional  disturbance  unless 
other  tissues  are  involved.  Of  course,  the  internal  glands — l)ronchial, 
mesenteric,  etc. — would  be  assumed  as  affected  in  addition  to  those  of 
the  axilla. 

The  pulmonar}'  signs  are  most  like  those  ordinarily  seen  in  acute 
bronchitis  with  bronchopneumonia,  but  the  duration  of  the  disease, 
^^•hich  is  more  than  a  month  at  least,  is  hardly  consistent  with  this  idea, 
and  makes  us  suspect  a  pulmonary  tuberculosis.  Further  eNidence 
can  be  obtained  only  by  the  sputum  examination.  The  cutaneous 
tuberculin  reaction  seems  to  be  of  little  value  in  patients  of  this  age, 
and  the  fever  precludes  our  trying  tlie  subcutaneous  reaction. 

Outcome. — When  first  (juestioncd,  the  patient  stated  that  he  had 
no  cough  whatever,  so  that  when  the  |)hysical  examination  was  under- 
taken we  liad  practically  no  clue  from  his  histor}'  regarding  the  source 
of  the  chills.  Later  he  acknowledged  that  he  did  cough  occasionally, 
and  on  the  thirteenth  of  October  a  little  glairy  sputum,  rcsemJ^hng 
sidiva,  was  o])tained.  It  seemed  hardly  \\ortb.  examination,  Ijut  to 
our  surprise  a  few  tubercle  bacilU  were  found  in  it.  The  patient  ])assed 
out  of  observation  October  i6th,  his  condition  ha\ing  become  steadily 
worse  meantime. 

Diagnosis. — Phthisis. 

Case  251 

A  man  of  sixty-eight,  a  dealer  in  sponges,  was  seen  Februan-  i, 
1908.  Thirty  years  ago  he  had  "Bright's  disease"  and  was  sick  for  a 
year.  He  has  had  "malaria"  off  and  on  for  thirty-five  years;  otf.er- 
wise  he  has  been  \\ell  until  se\en  }ears  ago,  when  he  Ijcgan  to  ha\'e 
"stomach  trouble,"  which  has  become  worse  in  the  last  three  months. 
This  is  characterized  by  pain  and  discomfort  in  the  epigastrium,  coniijig 
after  each  meal  and  lasting  twcj  or  three  hours.  His  a])pctite  has  been 
very  ])Oor,  and  for  six  weeks  he  has  li\"ed  mostly  on  liquids.  He  newr 
vomits  or  is  jaundiced. 

lie  i)asses  urine  eight  or  ten  times  at  night.  He  has  considerable 
frontal  headache,  no  cough  or  chspnea.  A  year  ago  he  weigf.ed  17S 
pounds;  now  he  weighs  134;  he  thinks  he  has  lost  chiclly  in  the  jKi-t 
three  months.  Four  weeks  ap^o  he  hegaii  to  have  ehil/s  coming  e\er\  day 
about  4  P.  M.     For  two  weeks  he  has  taken  20  grains  of  (uiinin  e\er\  day. 

When  examined,  the  patient  was  found  to  be  emaeia.ted,  with  adr}, 


472 


DIFFERENTIAL   DIAGNOSIS 


rough,  pale  skin.  There  was  no  dulness  or  bronchial  breathing  any- 
where in  the  chest.  There  were  crackling  rales  at  the  right  apex  in 
front,  scattered,  dry  whistling  sounds  below  the  right  clavicle,  and 
harsh  respiration  at  both  bases. 

The  hemoglobin  was  75  per  cent.  No  malarial  organisms  were 
found  after  repeated  examinations.  The  urine  was  normal;  Widal 
reaction  negative.  At  entrance  the  patient's  temperature  was  normal. 
(See  Fig.  115.)  It  soon  rose  and  remained  elevated  throughout  his  stay 
in  the  hospital.  By  the  stomach-tube  examination  no  fasting  contents 
were  recovered.     The  stomach  held  44  ounces,  its  lower  border  reaching 

just  below  the  navel.  After  a 
test-meal,  free  hydrochloric  acid 
was  0.05  per  cent.,  total  acidity, 
0.19  per  cent.  The  guaiac  test  was 
negative.  In  the  warm  Ijath  an 
edge,  distending  with  respiration, 
was  felt  in  the  right  h^'pochon- 
drium. 

The  patient  was  given  10  grains 
of  quinin  every  four  hours,  but  his 
temperature  was  not  much  affected. 
On  the  fourteenth  of  February 
there  was  bronchovesicular  breath- 
ing in  the  second  riglit  intercostal 
space  near  the  sternum,  with  in- 
tense whispering  bronchophony  and 
coarse  consonating  rales  after  cough. 
Otherwise  the  sounds  were  as  at 
entrance. 
Discussion.^Since  the  patient  has  apparently  had  malaria  for  a 
good  many  years  and  is  now  moderately  anemic,  it  is  proper  to  assume 
— until  proved  to  the  contrary — that  the  chills  of  which  he  now  com- 
plains are  of  malarial  origin.  This  idea,  however,  was  decisively  dis- 
pro\-ed  ]))'  the  blood  examination,  on  which  we  can  entirely  rely  in  such 
cases  if  it  is  made  by  any  one  who  has  had  the  proper  training. 

Can  there  be  any  connection  between  the  stomach,  of  which  he  com- 
plains so  much,  and  these  chills?  Tn  answer,  we  may  say,  I  think,  that 
unless  the  disease  has  extended  far  beyond  the  stomach  (e.  g.,  sub- 
I)hrenic  abscess  from  perforated  peptic  ulcer)  that  organ  is  incapable 
of  producing  such  a  clinical  |)icturc.  Phlegmonous  gastritis—that  very 
rare  disease— produces  a  far  more   fulminating  and  virulent  type  of 


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Fig.  115. — Chart  of  case  251. 


CHILLS 


473 


infection.  The  other  stomach  diseases  may  be  disregarded  in  our 
efforts  to  explain  the  chills. 

Since  the  edge  of  the  liver  is  felt,  it  is  proper  to  inquire  whether  any 
infection  in  or  near  that  organ  may  be  at  the  bottom  of  this  patient's 
troubles.  Provided  the  patient  has  no  leukocytosis  (a  point  on  which 
we  are  still  ignorant),  liver  infections,  whether  rising  from  the  gall- 
bladder, from  the  intestine,  or  otherwise — are  improbable.  The  upper 
border  of  the  organ,  especially  in  the  axilla  and  back,  is  almost  always 
raised,  as  percussion  will  demonstrate,  if  there  is  any  infection  in  or 
near  the  liver.  In  doubtful  cases  the  A'-ray  examination  may  help  us 
to  determine  the  outline  and  position  of  the  organ. 

The  pulmonary  signs  do  not  seem  at  first  examination  to  be  of  any 
special  significance.  Many  patients  of  sixty-eight  present  similar 
abnormalities,  off  and  on,  without  complaining  of  anything  in  particular. 
In  the  present  case,  however,  their  persistence  and  the  absence  of  any 
other  important  lesions  disco\'erable  by  physical  examination  lead  us 
to  focus  attention  uj^on  the  lungs.  Apparently  the  conditions,  whatever 
their  nature,  are  steadily  getting  worse. 

In  })atients  of  this  age  we  arc  rather  apt  to  forget  the  frequency 
and  importance  of  tuberculosis.  Statistics  show  that,  contrary  to 
the  imj)rcssion  current,  both  among  the  laity  and  among  medical  men, 
tuberculosis  is  just  as  prone  to  occur  in  the  latter  decades  of  life  as  in 
the  earlier.  In  this  case  we  are  tempted  still  further  away  from  the 
track  of  the  truth  because  the  patient  says  practically  nothing  about 
cough — indeed,  denies  that  he  has  had  any  pre^■ious  to  the  first  of 
February.  In  all  proljability  this  is  a  mistake,  and  in  view  of  the  steady 
increase  in  the  lung-signs  during  the  three  weeks'  period  of  observation, 
tuberculosis  seems  the  most  reasonal:>le  diagnosis. 

Outcome. — On  the  eighteenth  a  small  accumulation  of  free  lluid 
aj)])eared  in  the  })eritoneal  ca\"ity.  There  was  no  circulatory  weakness 
to  account  for  it.  The  ])atient  was  very  fussy  and  hard  to  ])lease,  de- 
claring that  he  had  no  saliva  and  no  secretion  from  his  stomach.  On 
the  twenty-first  he  Ix'camc  much  discouraged  and  insisted  u])on  going 
home.  Tubercle  bacilli  were  never  found  in  his  sputa  during  the  three 
weeks  of  his  stay  in  the  hospital. 

Diagnosis. — Phthisis  (?). 

Case  252 

An  Irish  laborer  fifty-four  }'cars  old  lost  his  fatlier  of  (.■on>um]iti(»n 
and  one  sister  of  the  same  disease.  His  wife  and  one  daugliter  are 
now  sick  with  "colds."     He  was  first  seen  February  i  ■;,  1907. 


474 


DIFFERENTIAL   DIAGNOSIS 


Thirty-eight  years  ago  he  was  seven  weeks  in  bed  with  "rheuma- 
tism," and  had  stiff  and  painful  joints  for  three  years  thereafter.  Thir- 
teen years  ago  he  had  a  right-sided  "pleurisy,"  but  was  well  in  a  few  days. 
He  denies  \encreal  disease,  but  for  ten  years  has  been  unable  to  hold 
his  urine  for  any  considerable  length  of  time  in  the  day,  though  he 
passes  it  only  twice  at  night.  As  a  rule,  he  does  not  drink  liquor 
to  excess,  but  a  week  ago  he  got  drunk  and  stayed  so  for  two  days. 

Two  weeks  ago  he  began  to  have  chills,  several  occurring  during 
one  night,  accompanied  by  cough  and  a  thick  white  sputum.  He  was 
unable  to  lie  down  on  account  of  the  distress  across  the  upper  abdomen. 

Two  days  later  he  had  a  sharp  pain  in  the 
lower  part  of  both  chests,  increased  by  cough  or 
breathing.  Pain  ceased  two  days  ago  in  the 
left  chest,  but  persisted  in  the  right.  He  has 
been  in  bed  for  the  past  three  days,  complain- 
ing of  pain,  ccugh,  and  weakness. 

The  course  of  the  temperature  is  seen  in  the 
accompanying  chart. 

Physical  examination  showed  no  enlargement 
of  the  heart  and  no  murmurs,  though  the  heart- 
sounds  were  irregular  in  force  and  rhythm.  The 
brachials  were  very  tortuous  and  showed  a  lateral 
exertion,  with  apparently  an  increased  tension. 
There  was  slight  dulness  in  the  lower  part  of 
both  backs  and  at  the  right  base  in  front,  o\"er 
which  area  there  are  a  few  crackles,  while  below 
the  right  nipple  there  was  heard  an  indistinct 
friction-rub,  \^•hich  on  the  seventeenth  had  become 
"'"'■"■  rougher  and  more  easily  audible. 

Discussion. — The  common  causes  of  oljscure  chills,  such  as  malaria, 
deep-seated  suppurations,  acute  endocarditis,  tuljerculosis,  and  nervous- 
ness, must  all  be  can\-assed  in  a  case  of  this  kind,  but  there  is  very 
little  to  substantiate  our  belief  in  any  one  of  them.  A  number  of  jjoints, 
however,  not  fully  stated  in  the  printed  account  must  be  further  in- 
vestigated. 

ia)  Nothing  is  said  about  the  urine.  In  men  of  this  age  an  old 
urethral  stricture,  with  or  without  prostatic  hypertro];hy,  urinar}-  reten- 
tion and  chronic  cystitis,  often  leads,  through  an  ascending  infection, 
to  j)yelonephritis,  and  thus  to  chills  like  tliose  here  described.  Investiga- 
tion of  the  urine,  howe\er.  showed  no  c\idence  of  any  such  disease. 
ib)   Nothing  is  said  about  the  size  of  the  liver.     Pain  in  the  upper 


Fig.   Ti6. — Chart   of    case 


CHILLS  475 

portion  of  the  abdomen,  associated  with  chills,  should  always  make  us 
look  for  evidence  of  liver  abscess,  gall-stone  disease,  or  subphrenic  suppu- 
ration. We  should  expect  a  leukocytosis  in  connection  with  any  of  these 
types  of  infection.  Nothing  is  said  about  the  leukocyte  count  in  the  his- 
tory printed  abo\e.  As  a  matter  of  fact,  however,  both  the  blood  and 
the  size  of  the  li\er  appeared  to  be  normal. 

(c)  It  is  well  known  that  alcoholism  is  often  associated  with  night- 
sweats  and  sometimes  with  chills.  So  far  as  I  know,  however,  both  of 
these  {phenomena  are  of  nervous  or  vasomotor  origin,  and  do  not  depend 
upon  any  variations  of  temperature,  such  as  are  shown  in  the  chart. 

On  the  whole,  the  chest  signs  seem  the  most  significant,  now  that 
we  have  excluded  some  of  the  other  possibilities.  Evidently  there  lias 
been  some  pleurisy  on  the  right  side,  possibly  on  both  sides,  though 
double  pleurisy  is  not  a  common  condition.  As  to  the  nature  of  this 
pleurisy,  it  is  hard  to  get  any  definite  information;  perhaps  only  the 
outcome  will  decide.  The  pleurisy  might  be  of  the  type  closely  asso- 
ciated with  lobar  pneumonia,  although  we  ha\'e  no  signs  of  that  disease. 
Many  cases  of  oljscure  septic  infection  by  pyogenic  organisms  atlect 
all  the  serous  meml)rancs  and  joint  surfaces  to  a  greater  or  less  extent, 
passing  ra])idh-  from  one  to  another.  Some  such  infection  may  well 
have  been  present  here.  Tuberculous  pleurisy  is  also  a  possiliility 
regarding  which  we  can  obtain  decisi\-e  information  only  by  following 
the  case  for  a  long  time. 

Outcome. — On  the  fifteenth  a  fine  friction-rub  was  also  heard  in  the 
left  lower  axilla,  and  this  persisted  until  the  twentieth. 

The  patient  was  given  a  tight  swathe  for  four  hours  and  a  teaspoon - 
ful  of  a  mixture  consisting  of  phosphate  of  codein,  8  grains,  potassium 
citrate,  3  drams,  syrup  of  hydriodic  acid,  4  ounces.  This,  with  a  bitter 
tonic  for  his  appetite,  made  him  able  to  lea\"e  the  hospital  on  the  twenty- 
fourth. 

Diagnosis. — Double  pleurisy  (septic?). 

Case  253 

A  court  officer  seventy-six  years  old,  of  good  family  histor}'  and 
past  history,  entered  the  hosjjital  March  18,  1908.  His  liabits  arc  good. 
He  has  had  chills  occasionally  c\er  since  the  Oi\"il  War. 

This  morning,  about  eight  o'clock,  while  on  the  train,  he  was  sci/id 
with  a  N-iolent  chill,  not  followed  by  sweating.  Since  then  he  has  fell 
very  sick  and  is  still  chilly,  but  has  no  pain  anywhere.  About  noon  he 
Vomited  four  times. 

At  no  ti  .ic  has  there  been  anv  cough. 


476 


DIFFERENTIAL   DIAGNOSIS 


Physical  examination  showed  in  the  left  back,  below  the  angle  of 
the  scapula,  slight  dulness,  distant  bronchovesicular  respiration,  in- 
creased fremitus,  and  medium-sized  crackling  rales.  There  were  a 
few  elevated  red  patches  the  size  of  almonds,  covered  with  crusts,  about 
the  left  ankle  and  shin.  The  white  cells  were  18,900;  urine  was  normal. 
The  temperature  was  as  seen  in  the  accompanying  chart  (Fig.  117). 

There  was  a  fme  trembling  all  o\'er 
whenever  the  man  moved.  There 
was  no  cough  and  no  sputa. 

Discussion. — The  point  which 
I  wish  to  insist  upon  in  this  case 
is  that  the  history  and  the  symp- 
toms give  no  indication  of  the  diag- 
nosis. 

With  a  careful  physical  ex- 
amination it  becomes  tolerably 
obvious  that  we  are  dealing  with 
a  lobar  pneumonia  (although  the 
signs  are  not  very  marked),  but  the 
diagnosis  must  rest  wholly  on  signs, 
as  there  is  no  cough,  rusty  sputa, 
or  pain  in  the  side.  The  chill  was 
confidently  attributed  by  the  pa- 
tient to  the  malaria  which  he  ac- 
quired in  the  Civil  War. 
Although  I  have  referred  to  the  disease  here  present  as  ''lobar 
pneumonia,"  it  is  more  than  probable  that  the  infection  is  not  so 
definitely  localized  and  involves  only  local  congestion  with  pleurisy  and 
perhaps  some  bronchopneumonia.  The  main  bulk  of  the  infection 
works  free  in  the  blood-stream. 

The  old  skin  lesions  about  the  left  ankle  have  no  relation  to  the 
symjjtoms  com])lained  of  in  this  case.  They  probably  represent  a  chronic 
eczema. 

Outcome. — On  the  twenty-first  the  white  cells  were  17,400,  and  on 
the  twenty-sixth,  27.000.  That  night  the  tem])erature  fell  by  crisis 
and  he  convalesced  without  incident. 

The  treatment  consisted  of  strychnin,  ^^  grain,  three  times  a  day, 
whisky,  i  ounce,  e\'cry  four  hours.  The  bowels  were  moved  by  glycerin 
enemata. 

Diagnosis. — Pneumonia. 


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Fig.  117. — Chart  of  case  253. 


CHILLS 


477 


Case  254 


A  cook,  forty-six  years  old,  was  seen  May  i,  1907.  She  has  one 
child  living  and  well ;  one  died  in  infancy.  She  has  had  two  miscarriages. 
Her  family  history'  is  excellent. 

Three  years  ago  the  patient  had  a  severe  sore  throat  which  had  to 
be  lanced  fifteen  or  twenty  times.  Since  that  time  her  voice  has  been 
thick. 

Seven  weeks  ago  she  began  to  have  chills  and  sweating  every  day  or 
two,  accompanied  by  persistent  nausea  and  vomiting.  For  the  past 
three  weeks  she  has  been  troubled  chiefly  with  cough,  thoracic  and 
epigastric  pain.  Throughout  her  illness  she  has  had  moderate  irregular 
fever  and  epigastric  tenderness.  Her  tempera- 
ture is  seen  in  the  accompanying  chart  (Fig.  118). 

The  patient  was  obese,  pale,  incoherent,  and 
almost  comatose.  There  was  marked  photo- 
phobia, so  that  the  pupillary  reactions  could  not 
be  obtained.  Through  the  soft  palate  there  was 
a  median  perforation  the  size  of  a  quarter  of  a 
dollar.  Behind  it  broad  white  bands,  probably 
old  adhesions,  could  be  seen.  The  heart-sounds 
were  faint  and  valvular  in  quality.  No  murmurs 
were  heard  and  no  enlargement  found;  the  lungs 
showed  nothing  abnormal.     Blood-pressure,  no. 

In  the  a]:)domen  there  was  general  tenderness, 
es])ecially  marked  in  the  epigastrium,  where  vague 
resistance  was  felt  behind  the  spastic  muscles. 
The  reflexes  were  normal.  The  white  count  was 
16,000;  i)olynuclears,  70  ])cr  cent.  There  were  no 
malarial  ])arasites.  The  urine  averaged  20  ounces 
in  twenty-four  hours,  1013  in  syjecific  gra\ity; 
albumin,  o.i  per  cent.,  a  few  coarse  granular  and  ejjithelial  cast^ 
Widal  reaction  was  ncgati\e. 

Discussion. — This  ])alient  had  l)ccn  working  ^"ery  hard  for  a  numl)er 
of  years  without  vacation,  and  the  diagnosis  of  her  attending  physician 
was  general  exhaustion.  But  the  c(Mi(iition  of  the  urine  made  it  at  once 
evident  that  something  more  serious  was  going  on.  AUhough  the 
])atient  is  febrile,  the  condition  of  the  urine  cannot  be  exj)laine(l  1  hereby, 
as  its  characteristics  are  not  those  ordinarily  associated  witli  fe\er.  On 
the  other  hand,  it  does  not  seem  like  nn\  of  the  more  familiar  l>l>e>  <>t 
ne])hritis.      It  has  not  the  concentration  and  blood\'  sediment   >een   in 


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case  254. 

The 


47' 


DIFFERENTIAL   DIAGNOSIS 


most  cases  of  acute  ne]:)hritis,  while  against  chronic  nephritis  is  the 
absence  of  any  cardiac  enlargement  or  hypertension. 

Leaving  for  the  time  undecided  the  problem  of  the  renal  condition, 
we  mav  start  from  one  of  the  most  certain  and  reliable  physical  signs 
present  in  the  case,  viz.,  the  perforation  of  the  soft  palate  and  the  adhe- 
sions between  it  and  the  posterior  pharyngeal  wall.  This  condition 
[practicallv  pathognomonic  of  syphilis  unless  there  is  a  history  of  the 
patient's  having  swallowed  some  caustic],  the  long-standing  hoarseness 
of  the  ^•oice,  the  chronic  sore  throat,  and  the  miscarriages  may  well  be 
accounted  for  in  the  same  way. 

Experience  shows  it  a  fairly  safe  rule  to  assume  that  any  acute 
manifestations  occurring  in  a  patient  with  unmistakable  lesions  of  a 
past  syphilis,  are  part  and  parcel  of  the  same  infection.  There  are,  of 
course,  exceptions  to  this  rule,  but  they  are  not  numerous.  If  now  we  re- 
turn to  the  attempt  to  explain  the  condition  of  the  kidneys,  we  notice 
that  the  urine  shows  the  characteristics  traditionally  associated  with  a 
syphilitic  type  of  nephritis  involving  amyloid  change.  In  this  kind  of 
disease  cardiac  hypertro])hy  usually  does  not  occur,  though  the  urine 
has  the  main  features  of  chronic  nephritis. 

We  get  no  hint  as  to  the  cause  of  the  chills  unless  it  be  the  epigastric 
tenderness  which  might  be  associated  with  hepatic  syphilis.  I  have 
known  this  disease  to  produce  chills  as  well  as  fever,  and  in  the  absence 
of  any  more  obvious  cause  we  may  conjecture  that  something  of  the  kind 
is  going  on  here.  It  is  quite  possible,  however,  that  some  acute  pyogenic 
infection  may  have  supervened. 

Outcome. — The  v/hite  count  steadily  rose  during  the  week  of  her 
illness,  reaching  25,000  on  the  fourth  of  ]May;  30,800  on  the  sixth; 
37,500  on  the  eighth.  The  urine  became  smoky  or  bloody,  the  albumin 
rising  to  0.8  per  cent,  despite  the  sweating  and  purging. 

In  the  last  two  days  the  pupils  ceased  to  react  and  the  lungs  filled 
with  coarse  crackles.     The  patient  died  on  the  ninth;  no  autopsy. 

Diagnosis. — Visceral  syphilis. 

Case  255 

An  Irish  housemaid  of  thirty-six,  whose  father  died  of  cancer,  was 
seen  August  30,  1907.  She  has  had  no  previous  illness.  Thecatamenia 
are  usually  painful  in  the  first  three  davs,  but  not  otherwise  abnormal. 

She  has  called  herself  perfectly  well  until  a  week  ago,  when  she 
awoke  with  a  stifi"  neck,  fever,  and  pain  in  her  neck,  back  and  hips. 
She  worked  that  day,  l)ut  the  next  day  had  to  go  to  bed,  and  has  been 
growing  worse  since.     She  has  been  seen  four  times  by  her  physician. 


CHILLS 


479 


who  thought  at  first  that  she  had  malaria,  as  she  had  frequent  chills 
during  the  first  three  days.  More  recently  he  thought  it  might  be 
pneumonia. 

The  bowels  have  moved  only  three  times  in  the  past  week.  Last 
night  she  had  a  chill  worse  than  any  of  her  previous  ones.  She  vomited 
a  great  deal  and  slept  very  little. 

(For  the  course  of  the  temperature  see  the  accompanying  chart, 
Fig.  119.) 

The  patient's  hair  is  nearly  all  white.  The  left  pupil  is  larger  than 
the  right,  both  reacting  normally.  She  has  marked  Riggs'  disease. 
The  throat  is  red,  the  tonsils  somewhat  enlarged.     The  chest  shows 


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nothing  abnormal.  The  abdomen  is  rather  full  l)elow  the  umbilicus 
and  slightly  tender  throughout.  The  spleen  is  not  pal])aljle.  The 
most  distressing  symptom  is  headache.  Her  head  can  be  bent  only  a 
sliort  distance  forward  or  sidewise,  and  then  with  e\"ident  ])ain. 

There  is  also  consideral)le  stiffness  of  the  spine  and  Kcrnig's  reac- 
tion is  j)resent  on  ])oth  sides. 

Luml)ar  puncture  was  done,  and  32  cm.  of  clear  lluid  withdrawn. 
No  cells  or  organisms  were  found  in  tlie  sediment.  The  white  cell-  at 
entrance  were  16,200.  On  September  2d  they  were  9600;  o)i  thr  .-i.\l!i, 
13,500;  on  the  eighth,  12.600. 

The  fundus  oculi  was  normal. 


480  DIFFERENTIAL  DIAGNOSIS 

On  the  sixth  of  September  she  passed  about  ^o  ounces  of  blood  by- 
rectum.  The  temperature  fell,  and  she  became  very  thirsty  and  per- 
spired profusely. 

The  next  day  her  extremities  were  cold  and  her  pulse  of  very  poor 
quality,  but  she  had  no  further  hemorrhage,  and  did  very  well  after 
the  sixteenth.  (See  accompanying  chart — ^Fig.  119 — of  the  tempera- 
ture.) 

Discussion. — Meningitis  is  very  strongly  suggested,  and  cannot 
be  positively  excluded,  but  the  characteristics  of  the  fluid  obtained  by 
lumbar  puncture  are  strongly  against  ever)'  type  of  meningitis  except 
that  due  to  tuberculosis,  and  not  characteristic  even  of  that. 

The  intestinal  hemorrhage  is  like  that  occurring  in  typhoid  fever, 
and  the  meningeal  symptoms  might  be  explained  as  meningismus,  i.  c, 
irritation  of  the  meninges  from  congestion,  toxemia,  or  edema,  without 
actual  inflammation.  Uncomplicated  typhoid  practically  never  pro- 
duces such  a  leukocytosis  as  is  here  present,  and  the  Widal  reaction 
is  absent,  although  this  fact  is  not  so  significant  in  a  case  like  this  seen 
early  in  the  course  of  the  disease,  as  it  would  be  in  the  later  weeks  of 
the  fever.  The  description  of  the  abdomen  is  quite  consistent  with  the 
signs  usually  present  in  tuberculous  peritonitis,  yet  the  clinical  picture, 
seen  as  a  whole,  is  very  different  from  that  of  peritoneal  tuberculosis. 
In  the  latter  disease  the  symptoms  and  signs  are  confined  almost  wholly 
to  the  abdomen  itself,  while  in  this  case  there  is  much  to  call  our  atten- 
tion elsewhere. 

A  rigid  search  was,  of  course,  made  for  any  local  infection  which 
might  cause  the  chills.  All  the  familiar  situations  in  which  deep- 
seated  suppuration  conceals  itself  (the  ears,  the  deeper  portions  of  the 
axilla,  the  perirectal  tissues,  the  hepatic  region,  the  urinary  tract,  the 
pericardium)  were  examined,  with  negative  results. 

Finding  no  other  satisfactory  diagnosis,  we  naturally  return  to 
typhoid  with  some  complication  producing  chills.  What  can  that 
complication  be?  In  the  reports  of  the  Johns  Hopkins  Hospital  (\'ol. 
V,  p.  445)  is  a  study  of  chills  occurring  in  typhoid  fever.  The  following 
causes  are  discussed: 

(a)  Chills  at  the  onset  of  the  disease. 

(b)  Chills  at  the  onset  of  a  rela])se. 

(f)  Chills  at  the  onset  of  complications  (phlebitis,  cholecystitis, 
pleurisy,  pneumonia,  otitis,  periostitis). 

(d)  Chills  as  a  result  of  treatment  (antipyretics,  antityphoid  vaccina- 
tion, and  intravenous  saline  infusion). 

{e)    Chills  due  to  concurrent  malaria. 


CHILLS 


48  r 


(/)    Chills  due  to  unknown  cause  (sepsis?)  in  protracted  cases. 

In  the  present  case  we  must  classify  the  chills  under  the  last  heading 

if)- 

Outcome. — On  the  sixteenth  of  September  the  Widal  reaction  l^e- 
came  positive.  On  the  twenty-fifth  of  September  it  was  noticed  that 
for  a  number  of  days  she  had  been  passing  only  from  one-third  to  one- 
fifth  as  much  fluid  by  the  urethra  as  she  took  in  by  mouth,  although 
there  was  no  consideraljle  amount  of  sweating  and  the  bowels  were 
normal.  This  remarkable  retention  of  fluid  was,  doubtless,  necessary 
in  order  to  make  up  for  the  losses  suffered  both  by  hemorrhage  and  as 
a  result  of  the  fever  itself.  She  continued  to  improve  steadily  and  \\  ent 
home  perfectly  well  on  the  third  of  Novemljer. 

Diagnosis. — Typhoid. 

Case  256 

A  glazier  of  twenty-four,  whose  father  died  of  consumption,  was  seen 
November  13,  1906.  He  has  been  perfectly  well  all  his  life,  but  takes 
two  or  three  glasses  of  whisky  and  three  or  four  of  beer  every  day. 

The  temperature  curve  is  seen  in  the  following  four-hourly  chart: 


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Fig.  120. — Chart  nf  rase  256. 

Ten  days  ago  he  had  a  cliill.  followed  by  sweating  and  wcaknos. 
These  chills  ha\e  recurred  e\er  since  that  time,  usualh'  bclv.i'cn  7  iind 
8  P.  M.     The  chills  arc  accompanied  by  pain  in  the  left    >i(lc    of   the 

31 


482 


DIFFERKNTIAL   DIAGNOSIS 


chest  and  in  the  back.  They  usually  last  an  hour  and  are  accompanied 
by  vomiting.     He  has  been  in  bed  two  days. 

Physical  examination  was  entirely  negative.  White  cells,  7000. 
Hemoglobin,  75  \)er  cent. 

Malarial  parasites  were  repeatedly  sought  for,  but  never  found. 
The  })olynuclear  cells  made  up  88  per  cent,  of  the  leukocyte  ]jercentage. 
XMdal's  reaction  was  always  negative.  The  patient  looked  sick  and 
toxic.     No  diagnosis  was  made. 

On  the  se\'entecnth  of  No^•ember,  in  the  course  of  a  routine  examina- 
tion of  all  parts  of  the  body,  an  area  of  reddening  and  brawny  induration 
was  found  in  the  left  buttock,  extending  along  the  perineum  and  up  to 
the  groin.  The  patient  had  made  no  complaint  of  pain  in  this  region. 
The  white  cells  were  now  17,000. 

Discussion. — In  cases  characterized  by  chills  and  fever,  when 
malaria  and  neurasthenia  can  be  excluded,  the  only  proper  course  for 
the  physician  is  to  keep  on  looking,  day  after  day,  by  repeated  and 
searching  physical  examinations,  for  some  local  cause.  Typhoid 
fe\cr  is,  of  course,  a  possibility  in  a  case  of  this  kind,  but  the  high  per- 
centage of  polynuclear  cells  and  the  continued  absence  of  a  Widal 
reaction,  after  a  period  of  at  least  two  weeks  from  the  ]:)eginning  of 
the  illness,  makes  this  unlikely. 

The  left  chest  was  repeatedly  examined  for  e\'idence  of  pleurisy 
or  empyema,  but  at  no  time  were  there  any  physical  signs  of  disease 
discoverable  there. 

Tuberculosis  and  meningitis  were  considered,  but  could  not  be 
verified. 

The  |)oint  at  which  the  suppuration  was  finally  found  is,  I  think, 
a  rather  frequent  one  in  cases  of  this  kind.  Sometimes  we  fail  to  fmd 
it  because  the  ])aticnt's  modesty  and  our  own  too  limited  physical 
examination  gives  us  no  hint.  In  other  cases  I  believe  that  the  su])- 
puralion  actually  causes  no  jxiin  or  recognizable  physical  sign  until 
it  reaches  the  surface  of  the  bod}-,  or,  at  any  rate,  the  subcutaneous 
tissues.  Another  possiljility,  which  the  more  frequent  use  of  blood 
cultures  of  late  years  has  brought  to  our  attention,  is  that  the  chills 
were  y)roduced  by  a  non-localized  bacteremia  which  later  manifests  itself 
as  an  abscess. 

Outcome. — 0])cration,  November  i8th,  liberated  nearly  a  ])int  of 
l>us.  The  temperature  fell  at  once,  and  the  i)atient  went  home  well 
three  weeks  later. 

Diagnosis. — Ischiorectal  abscess. 


Fig.  121.— Results  of  jjhysical  examination  in  Case  257.       Complaints:  chills  and  "old- 
fashioned  stomach  trouble." 


CHILLS 


483 


Case  257 

An  old  lady  of  seventy-one  was  first  seen  September  28,  1909.  Twentv 
years  ago,  follovvmg  the  menopause,  she  had  two  or  three  chills  at  inter- 
vals of  forty-eight  hours.  No  other  symptoms.  Since  that  time  she  has 
had  one  or  more  similar  attacks  e\'er}-  year  without  known  cause  or 
relation  to  seasons.  Quinin  has  often  been  given  her,  but  has  no  appre- 
ciable effect. 

No  other  symj^toms  occurred  until  live  weeks  ago,  when  she  had 
an  attack  of  what  she  called  "ordinary  old-fashioned  stomach  trouble," 
/.  c,  an  ejjigastric  pain  which  "cut  its  way  through  the  right  side  to 
the  back."    There  was  vomiting  with  this.      These 
attacks  ha\e  recurred  every  second  day  ever  since. 
The    pain   is  usually  controlled    by  drugs.     Her 
appetite  has  been  failing  for  five  weeks.     Her  stools 
have  ne\er  been  light  colored,  and  she  has  never 
been  jaundiced.     Now  she  feels  well  and  strong. 
(See  Figs.  121  and  122.) 

Discussion. — The  patient  was  an  exceedingly 
intelligent  and  frisky  old  lady  who  said  what  she 
meant  and  meant  what  she  said,  so  that  I  belicxe 
that  she  really  had  had  chills  off  and  on  for 
twenty  years — a  remarkably  interesting  history. 

In  a  woman  of  a  different  type  one  might 
sus])ect  that  these  chills  were  of  the  nervous 
\ariety,  but  no  one  who  con\crscd  for  any  length 
of  time  with  this  patient  could  entertain  such  a 
suj)j)Osition. 

There  \\as  al)solutcly  notliing  in  the  i^liysical 
examination  to  suggest  any  source  or  cause  for 
the    chills.      She    had    ne\cr    been    in    a    tro|)ical 

countn"  where  she  could  lia\'e  acquired  relapsing  fc\er.  She  had  no 
sign  whate\er  of  Ifodgkin's  disease.  Tliere  is  l)ut  one  other  common 
cause  for  a  relapsing  or  recurring  t\i)e  of  fc\er,  such  as  we  ma_\'  a>-uine 
to  have  accf)mpanied  this  patient's  chills,  \iz.,  gall-stone<. 

This  latter  ])ossibilit_\' — gall-<tone  disease — is  borne  out  b\-  the    al 
tack  of  so-called  stomach  trouble,  for  niaiu'  gall-stone  pains  art'  rrlrrrtd. 
as  in  this  (■a>t',  to  the  epigastrium.     The  most  sur])rising  featuri',  liow  r\rr. 
of  the  ca-^t'  and  the  greatest  diHicultv  with  our  diagnosis  of  gall  -tone- 
i>  thr   rntirr  ab-fuce  of   jaundice.      It   i-  \v\k\  of  cour-c.   thai    nian\ 
])erluip-   mo^t     ca>es  of  gail-^tone  run   their  cour-e   without    jaundice, 


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484 


DIFFERENTIAL   DIAGNOSIS 


but  the  particular  type  of  trouble  which  is  prone  to  produce  recurrent 
attacks  of  fever  with  chills— common  duct  stone  with  infection — ^almost 
always  causes  jaundice. 

Outcome. — As  the  patient  refused  operation  and  soon  left  the  hospital 
with  a  rather  low  opinion  of  the  modern  medical  profession,  we  have 
no  absolute  proof  that  our  diagnosis  of  gall-stones  is  correct,  but  I  feel 
no  considerable  doubt  of  it,  for  we  learned  later  that  in  a  previous  attack 
one  of  her  physicians  had  found  yellowing  of  the  conjunctivas  and  bile 
in  the  urine. 

Diagnosis. — Gall-stones. 

Case  258 

A  married  woman  of  thirty-one  was  seen  October  7,  1909.  She 
has  been  working  excessively  hard  for  six  weeks,  caring  for  four  children 
at  home  and  working  to  support  them  during  the  illness  of  her  husband. 

Has  been  ver)-  short  of  food  and  sleep. 

One  week  ago  she  had  a  sudden  severe 
chill  and  vomiting.  Three  days  ago  began 
to  cough,  raising  considerable  yellow  or 
brownish  sputa.  No  pain,  no  headache,  no 
chill,  or  vomiting,  after  the  first  day.  Now 
suffers  from  great  exhaustion,  anorexia,  con- 
stipation, and  racking  cough  which  disturbs 
sleep. 

Examination. — (See  Fig.  123.) 
Marked  herpes  labialis.     Chest  and  belly 
negative.     Urine  and  sputa  negative.     Leuko- 
cytes October  8,  11,500;  October  13th,  19,000. 
No  localizing  evidence. 

Discussion. — Since  we  were  unable  to 
find  any  e\'idence  of  lobar  pneumonia  or 
of  l^ronchopneumonia,  we  began  to  think 
that  the  case  must  be  one  of  those  uncharted, 
unnamed  infectious  diseases  ordinarily  called 
"gri])."  There  was  not  a  ])article  of  e\-idence  pointing  to  any  part 
of  the  body  as  the  scat  of  an  abscess  or  inflammation.  I  rather 
think  this  was  due,  in  part,  to  the  fact  that  we  had  not  in  mind  any 
list  of  the  "likely  ])laces"  where  cxi)erience  has  shown  that  obscure 
suppurations  arc  ])r()ne  to  occur.  Among  these  we  should  have  remem- 
bered a  deep  axillary  abscess. 

Nevertheless,  in  \iew  of  the  sym])toms  with  which  the  disease  began 


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2vH. 


CHILLS 


485 


— the  cough,  sputa,  herpes,  and  vomiting — I  do  not  beHeve  that  the 
inflammation  was  localized  from  the  start  in  the  axillary  region.  In 
other  words,  when  we  were  looking  most  fruitless!}-  for  a  local  source 
of  infection,  there  was  no  such  local  source.  That  was  a  later  chapter. 
Perha])s  in  the  earlier  stages  of  the  disease  a  blood  culture  would  ha\  e 
revealed  the  actual  nature  of  the  trouble. 

Outcome. — October  14th  a  swollen,  tender  mass  was  found  in  the 
left  axilla.  On  the  surface  of  the  indurated  tissues  a  few  small  glands 
could  be  felt;  underneath,  a  deep  fluctuation  (?)  was  detected.  Incision 
released  se\eral  ounces  of  very  foul  pus  and  re\ealed  a  cavity  extending 
far  back  under  the  scaj)ula.  The  temperature  fell  after  the  establish- 
ment of  the  drainage,  and  in  ten  days  the  patient  was  well. 

Diagnosis. — Deep  axillary  abscess. 


TAliLK    XII.— Chills.     Signs  and  Symptoms. 


Nepativt 


Local  sigii^ 


Relief. 


Reassurance. 
Discipline. 


ryogenic  sepsis 


R...      .  r       1  .      ■  At  source  of  infec-  Absorption  or 

emittcnt.  Leukocytosis.  .  ...  ,     .' 

'  tion,  or  in  heart.  draiiiaee. 


I'htViisis 


Remittent. 


Usually 

leukocvtosis 


Lungs.     Sputa.         Hygienic  measures. 


Pneumonia 


Continued. 


Usually 
leukocytosis. 


Lungs.     Sputa. 


liy  progress  of 
disease. 


Gall-stones 


Remittent.  Not  charactcristii 


Colic. 
Jaundice  ('.'1. 
Knlarged  gall- 
bladder \;'.). 


Morphin.      Opera- 
tion.    Passage  of 
stone. 


.Malaria 


I'arasites. 
eukopenia 


Knlarged  spleen. 


Typhoid  fever  (onset)     .    .  Coiitiinied. 


I. eukopenia. 

Widal    test. 

liacilli  bv  culture 


Rose  spots.  Hy  progress  of 

Knlarged  spleen.  disease 


CHAPTER  XV 

COMA 

EXAMINATION  OF  COMATOSE  OR  CONVULSIVE  PATIENTS 

I.  CERTAIN  HOARY   ERRORS   TO  BE  AVOIDED 

1.  Make  no  diagnostic  inferences  from  squints  or  inequalities  of  the 
pupils,  and  be  cautious  in  all  conclusions  drawn  from  pupillary  con- 
tractures or  dilatations.  In  the  majority  of  comatose  cases  the  state  of 
the  pupils  gives  us  no  valuable  information.  Lack  of  response  to  light 
is  proportional  to  the  depth  of  the  coma,  and  in  hysteric  states  the 
responses  are  usually  normal. 

2.  Conjugate  deviation  of  the  head  and  eyes  has  at  present  no  di- 
agnostic value.  I  have  seen  it  in  sunstroke  and  in  uremia  when  the 
autopsy  showed  no  local  lesions  whatever. 

3.  Stertorous  breathing  (often  mere  snoring)  means  simply  deep 
coma  from  any  cause.  It  is  not  characteristic  of  apoplexy  or  of  any 
other  disease. 

4.  Albumin  or  sugar  in  urine  with  or  without  casts  have  usually  no 
significance.  The}'  are  far  more  often  seen  in  non-uremic  than  in 
uremic  cases,  for  they  may  occur  in  deep  coma  from  any  of  its  numerous 
causes.  In  uremic  cases  we  have  the  history,  the  condition  of  the  heart 
and  fundus  oculi,  and  usually  the  evidences  of  dropsy  to  guide  us. 

5.  Hemorrhage  from  the  ear  often  accompanies  a  coma  due  to  frac- 
ture of  the  base,  but  it  is  by  no  means  pathognomonic  of  this  condition, 
as  injuries  to  the  tympanum  or  external  auditory  meatus  may  also  cause 
bleeding. 

6.  Hemiplegia,  aphasia,  and  Jackson ian  epilepsy  may  occur  in  coma 
due  to  uremia  or  other  non-localized  brain  irritation.  They  are  not 
proof  of  focal  disease. 

11.  CAUSES  OF   COMA  AND  CONVULSIONS 

These  two  manifestations  of  ccrcbros])inaI  disturbance  cannot  well 
be  studied  sc])arately,  since  ])ractically  all  causes  of  coma  are  also 
causes  of  con\iilsions  and  \ice  \'ersa. 

4Hf) 


Causes  of  Coma 


1.  ALCOHOLISM 

2.  "SYNCOPE" 

3.  "  APOPLEXY  "» 


EXHAUSTION     I  ^^^^^^^^^^^^^^^^^^^^ 

5.  UREMIA  ^mi^^^mmi^^  211 

6.  MENINGITIS  I^HBBHII^H  172 


7.  DEMENTIA 

PARALYTICA 


49 


8.  BRAIN    TUMOR  ■}  19 

1  Altlioiigh  we  have  treated  at  the  Massachusetts  Hospital  only  62  cases  fm  coma  due 
to  a[50plexy  during  the  six  years  covered  hv  this  report,  the  statistics  of  mortality  from 
apoplexy  convince  me  that  this  disease  must  be  among  the  commonest  causes  for  coma. 
The  patients  arc  treated  at  home. 


l-iT 


COMA 


489 


The  following  exceptions  may  be  noted: 

(a)  Opium  and  sunstroke  cause  coma,  but  very  rarely  convulsions. 

(b)  Strychnin  and  tetanus  cause  convulsions,  but  rarely  coma. 
Otherwise  the  whole  list  of  diseases  shown  in  the  table  below  are 

causes  of  both  symptoms. 


CAUSES  OF  COMA  AND  CONVULSIONS 


Diseases. 


I.  Brain  injuries  or  dejects: 

1.  Concussion  and  traumatic  edema  ^ 

2.  Compression  and  laceration  (with  or  with- 

out hemorrhage) 

3.  Congenital  defects,"  with  or  without  hydro- 

cephalus, hemi[)legia,  or  idiocy 

II.  Brain  diseases: 

(a)  Meningitis  (all  types)  . . . 
{b)   Apoplexy  '^ 

(c)  Tumor  and  abscess 

(d)  Sclerosis           (dementia 
paralytica) 

(e)  Syphilis 

\Mth  microscopic  lesions:  Epilejisy 


With  gross 
lesions: 


III.  Infectious  diseases  {e.  g.,  tetanus,  typhoid,  ty- 

phus, pyogenic  sepsis,  pneumonia,  trypano- 
somiasis, malaria,  etc.): 

IV.  Poisons: 

1.  Alcohol 

2.  Illuminating  gas 

3.  Lead 

4.  Opium 

5.  Strychnin 

6.  Uremia 

7.  Eclampsia  (puerperal) 

8.  Hepatic  toxemia 

9.  Diabetic  acidosis,  cachexia  of  cancer,  and 

j)ernicious    anemia 

V.  Syncope  and  cardiac  weakness: 

1.  "Simple  fainting" 

2.  Stokes- Adams'   disease 

3.  Valvular  or  myocardial  disease.    

4.  Pleural  irritation  (as  during  irrigation)  .  . .  . 
VI.  Sunstroke 

Vn.    ])i!^estt'ir  and  iujrctious  disorders  oj  injancy. .  . 
\'III.  Hysteria  and  malingering 


Coma . 

Convulsions. 

Often 

Occasionally 

Often 

Occasionally 

Occasionally 

Often 

Often 

Occasionally 

Often 

Occasionally 

Often 

Occasionally 

Occasionally 

Often 

Often 

Occasionally 

TrTi-Q,-;nt,1,. 

or  in  status  epi- 
lepticus 
Late 


Often 


Often 

Occasionally 

Often 

Oicasionalh 

Often 

Rare 

Occasionally 

Oc(  asionalh 

Often 

45  P^T  cent. 

Often 

Often 

Often 

Often 

Early  (in  children 
and  in  tetanus) 


Often 

Occasionally 

Often 

Occasionalh 

Rare 

Rare 

Often 

\'ery  rare 

Rare 

Often 

Often 

Often 

Often 

Often 

Often 

Often 

Rare 


*  Also  called  "serous  meningitis."  "  Including  birth  jialsirs  anri  accidents. 

^Including  cerebral  hemorrhage,  thrombosis,  embolism,  and  softening. 


49° 


DIFFERENTIAL    DIAGNOSIS 


In  the  \ast  majority  of  adults  the  cause  of  any  coma  or  con\ulsion 
will  be  found  to  be: 

(a)  A  brain  disease,  injury,  or  defect. 

(b)  An  infection. 

(c)  A  poison. 

((/)  A  form  of  cardiac  insufficiency. 

The  details  included  in  these  four  headings,  together  with  three  other 
and  less  common  types,  are  shown  in  the  table  on  p.  489. 

III.  VALUABLE  CLUES 

I.  The  History. — It  is  always  of  the  greatest  importance  to  question 
carefully  any  available  relatives  or  friends;  indeed,  it  is  usually  more 
valuable  than  the  physical  examination.  Most  of  the  mistaken  diagnoses 
in  comatose  or  convulsive  states  are  due,  in  my  experience,  to  the  lack 
of  a  good  history. 

(a)  In  comatose  patients  with  head  injuries  it  is  essential,  though 
often  impossil^le.  to  ascertain  whether  the  injury  caused  the  coma  or 
the  coma  the  injury.  A  man  falls  from  a  scaffolding  and  strikes  his  head. 
Did  he  fall  because  he  was  already  unconscious — perhaps  from  cerebral 
hemorrhage?  His  comrades  may  be  able  to  tell  us.  Another  useful 
datum  in  "head  cases"  is  the  order  of  symptoms,  and  their  relation 
to  the  time  of  the  injury.  In  concussion  and  traumatic  edema  the 
coma  is  immediate  and  any  focal  symptoms  (paralysis,  aphasia,  etc.), 
come  later.  In  traumatic  cerebral  hemorrhage  there  is  often  an  interval 
ot  hours  or  days  between  the  injury  (e.  g.,  a  boxer's  blow)  and  the  focal 
])aralysis  which  next  makes  its  appearance.     Coma  comes  later  still. 

{b)   A  clear  history  of  syphilis  is  ob\'iously  an  important  clue. 

(6")  The  mental  and  motor  changes  of  dementia  paralytica  should 
always  be  carefully  inquired  into  when  an  ''epilepsy"  or  a  ''fainting 
s])eir'  ai)pears  for  the  first  time  after  the  fortieth  year.  Fainting  and 
epilepsy  almost  never  begin  after  forty. 

(d)  Cases  of  poisoning  by  alcohol,  opium,  lead,  or  gas  are  usually 
seen  under  conditions  wliich  make  the  history  (and,  therefore,  the 
diagnosis)  clear.  Jiut  in  ])olice  stations,  where  the  Saturday-night 
"drunks"  are  gathered  in,  the  (juestion,  "Drunk  or  dying?"  not  infre- 
(|uently  arises.  Cases  of  alcoholic  pneumonia — more  or  less  comatose 
and  delirious — are  Iraited  and  die  as  "common  drunks"  because  the 
temperature  and  the  lung  signs  are  not  investigated.  Cerebral  hemor- 
rhage may  occur  during  a  drinking  bout,  and  the  obvious  odor  of  alcoliol 
may  then  ])re\ent  our  n^aking  any  distinction  between  the  drunk  and  the 
(h'in<{. 


COMA  491 

(e)  Uremia,  without  any  pre\'ious  history  of  the  ordinan-  symi)toms 
of  nephritis,  is,  I  beUeve,  a  very  rare  occurrence,  when  the  physical 
examination  leads  to  the  diagnosis  of  uremia  and  the  history  does  not 
support  such  a  diagnosis. 

2.  The  Physical  Examination. — (a)  The  temperature  is  most  a|)t 
to  thro\\-  light  upon  the  case  if  a  normal  reading  is  found,  for  thereby 
Ave  can  usually  exclude  the  acute  infections  as  causes  of  coma  or  convul- 
sions. \'ery  high  temperatures  (107°,  110°,  115°  F.)  are  strongly  sug- 
gestive of  sunstroke  if  the  weather  gives  any  countenance  to  the  idea. 

{h)  A  sloii  pulse  occurs  especially  with  tumors,  injuries,  and  infections 
of  the  brain;  less  often  in  opium-poisoning. 

(c)  EA'idence  of  cardiac  hypertrophy  and  vascular  hypertension  are 
of  importance  as  suggesting  that  the  brain  or  the  kidney  is  the  source 
of  the  trouble. 

(d)  The  })resence  of  a  lead  line  and  of  basophilic  stippling  in  the 
red  corpuscles  is  occasionally  of  the  greatest  importance,  and  should 
always  be  sought  for  in  doubtful  cases. 

(e)  Evidences  of  hemiplegia  (unilateral  increase  of  knee-jerk, 
Babinski's  reaction,  increased  or  diminished  muscular  tonicity  on  one 
side  of  the  body,  unilateral  analgesia)  ])oint  toward  the  l)rain,  but  not 
necessarily  toward  any  gross  lesion  therein,  since  hemiplegia  may  occur 
without  any  such  lesion  in  uremia  and  in  epidemic  meningitis. 

(/)  Lesions  suggesting  syphilis  are  sometimes  disco\erable  in  the 
bones,  glands,  skin,  or  naso]jharynx.  The  presence  of  such  lesions 
gives  us  ground  for  suspecting  that  similar  disease  of  the  brain  may  be 
rcs]jonsil)le  for  the  coma  or  convulsions  which  we  arc  studying. 

(g)  Spinal  puncture  may  gi\'e  us  information  of  life-saving  value, 
as,  for  examjjle,  in  epidemic  meningitis.  More  often  it  may  help  us  to 
identify  a  syphilitic  or  metasy])hilitic  lesion. 

3.  The  Recognition  of  Hysteric  States. — There  is  only  one  way 
of  being  comatose,  and,  sa\e  for  the  ])cculiarities  of  indi\iduals,  there 
are  no  distinguishing  marks  or  qualities  in  any  of  the  varieties  of  coma 
alK)\e  referred  to.  Their  causes  are  distinguished  l)y  the  accom])any- 
ing  ])hysical  signs  or  by  tlie  history,  not  h\  the  characteristics  of  the 
coma  itself. 

Hysteric  states  are  rarel}'  true  coma,  and  the  distinction,  which  ma\ 
be  of  considerable  importance,  rests  mainh'  u])on  the  foUowing  ixiiiU-: 

un  By  a])i)ro])riate  stimulus  the  patient  can  be  rouM'd.  'J'hi-- 
>tinnilus  may  be  a  i)ail  of  water  or  a  well-chosen  remark.  Thf  jiatii'nt 
ma\',  liowewr,  be  (juite  insensible  to  pain,  and  apparent!}'  -o  lo  noi.-c 
or  liuht. 


492  DIFFERENTIAL   DIAGNOSIS 

{b)  The  motions  or  attitudes  during  the  apparently  unconscious 
period  are  usuall}'  semivoluntar}'  or  purposive.  Grasping  movements 
and  etYorts  at  resistance,  as  when,  for  example,  the  nose  and  mouth  are 
covered,  are  especially  characteristic.  The  clonic  spasms  which  so 
often  occur  in  coma  are  not  seen  in  hysteria.  Hypertonicity  and  opis- 
thotonos are  frequently  seen. 

(c)  Tremor  or  flickering  of  the  eyelids  and  rolling  up  of  the  eye- 
balls are  very  common, 

(d)  In  falling,  the  patients  almost  ne^•er  hurt  themselves,  and  during 
the  convulsions  there  is  rarely  any  biting  of  the  tongue  or  relaxation  of  the 
sphincters.     Often  there  is  confused  talk  or  screaming. 

I  will  now  exemplify  a  few  of  the  causes  of  coma;  many  others  will 
be  found  in  the  chapter  on  Convulsions,  because  the  spasm  was  more 
striking  than  the  coma  in  these  cases. 

Case  259 

A  Russian  housewife  of  forty-eight,  whose  father  died  of  a  "cold  in 
his  foot,"  ^  had  typhoid  iexer  in  childhood,  but  has  othenvise  been  well 
all  her  life.     She  passed  the  menopause  three  years  ago. 

For  three  or  four  months  she  has  complained  of  "rheumatic"  pains 
in  her  limbs,  with  headache,  constipation,  and  loss  of  appetite.  For 
two  or  three  days  she  has  had  distress  about  the  precordia.  To-day 
at  I  P,  M.  this  distress  increased  until  she  was  forced  to  lie  down,  follow- 
ing which  she  became  comatose.  After  two  or  three  minutes  she  regained 
consciousness  and  screamed  violently  for  se^•eral  minutes  on  account 
of  precordial  pain,  which  apparently  did  not  radiate  at  all. 

These  attacks  recurred  e^■ery  ten  to  fifteen  minutes  until  seven  in 
the  evening.  She  \omited  six  or  seven  times  during  the  afternoon,  and 
when  seen  at  ii  p.  m.,  complained  of  palpitation  and  a  sense  of  weakness 
about  her  heart, 

A  physician  who  saw  her  in  one  of  her  "fainting  attacks"  previous 
to  her  entering  the  hospital  said  that  she  was  practically  pulseless  during 
the  period  of  unconsciousness. 

Subsequently  it  was  learned  that  she  had  been  subject  to  fainting  at- 
tacks for  over  thirty  years,  and  had  had  a  goiter  for  the  same  length  of  time. 

Physical  examination  re\ealed  the  tumor  above  referred  to,  which 
was  about  the  size  of  a  hen's  egg,  situated  in  the  median  line,  smooth, 
rounded,  not  tender,  moving  with  the  larynx  on  swallowing. 

U])on  inspection  the  heart's  impulse  was  ^•ery  diffuse,  apparently 
extending  a  half  inch  outside  the  nip])le  in  the  fifth  space.     There  were 

^  Gangrene  presumably. 


COMA 


493 


no  murmurs,  and  physical  examination  was  otherwise  negati^■e;  blood 
and  urine  normal. 

The  patient  presented  chiefly  the  picture  of  exhaustion.  She  com- 
plained of  \arious  pains  in  her  arms  and  legs.  The  pulse  during  most 
of  her  stay  in  the  hospital  was  very  irregular,  but  there  was  no  repetition 
of  the  attacks  of  syncope. 

On  Februar}^  7th,  when  the  pulse  was  no,  there  was  noticed  a  pulsa- 
tion in  the  jugular  veins,  filling  from  below  at  exactly  twice  the  rate  of 
the  arterial  pulse.  On  the  eighth  there  were  three  beats  in  the  neck  for 
every  one  at  the  wrist. 

Discussion. — Fainting  attacks  often  repeated  usually  turn  out  to 
be  due  to  some  important  underlying  disease.  One  should  alwa}s 
look  with  great  suspicion  upon  any  attack  so  designated  if  it  is  known 
to  have  occurred  frequently.  Hysteria  is  perhaps  the  disease  which 
turns  out  most  frequently  to  be  the  cause  of  attacks  of  this  nature, 
but  I  have  known  also  cases  of  nephritis,  of  cerebral  tumor,  and  of 
ejjilepsy  which  have  been  called  "fainting  attacks"  for  months  or  years 
before  the  real  cause  was  recognized. 

In  the  present  case,  since  physical  examination  is  so  nearly  negatixe, 
the  most  important  diagnostic  feature  is  the  report  by  the  physician 
v.ho  watched  her  in  one  of  these  fainting  attacks  and  noticed  that  she 
was  practically  pulseless.  In  the  absence  of  any  obvious  \'alvular 
disease,  this  obser\'ation  should  lead  us  to  suspect  disease  of  the  myo- 
cardium and  to  study  very  carefully  the  condition  of  the  neck  \eins 
during  attack. 

Outcome. — February  7th  it  was  noticed  that  the  jugular  veins 
filled  from  below  and  pulsated  at  exactly  twice  the  rate  of  the  arterial 
pulse.  After  two  weeks'  rest  in  bed  and  the  administration  of  iodid  of 
potash  the  patient  seemed  much  l)enefited.  She  was  seen  two  years  later 
and  stated  that  she  had  had  no  recurrence  of  the  "fainting  fits,"  although 
from  once  a  month  to  once  in  three  months  she  had  had  severe  attacks 
of  precordial  pain  relieved  by  rest  and  applications  of  heat.  She  no\\' 
passes  water  two  or  three  times  each  night,  and  has  had  \anous  attacks 
of  infectious  arthritis  and  one  of  erysipelas.  The  goiter  remains  un- 
changed. 

Diagnosis. — Stokes- Adams'  disease. 

Case  260 

An  unmarried  Russian  seamstress  of  tucnty,  whose  motlier  died  of 
diabetes,  lost  her  fatlier  and  one  sister  of  tuberculosis.  Three  brothers 
and  one  sister  are  well. 


494 


DIFFERENTIAL   DIAGNOSIS 


The  patient  herself  became  much  run  down  fne  years  ago  and 
was  sent  into  the  country,  apparently  for  suspected  tuberculosis,  though 
her  cough  was  not  very  persistent,  and  her  sputa  was  never  examined. 
She  was  first  seen  April  14,  1908. 

Four  days  ago  she  became  excited  and  fell  unconscious.  There 
were  no  convulsion  and  no  paralysis,  but  she  was  somewhat  rigid  during 
the  attack,  and  she  has  since  then  been  in  bed  and  has  vomited  every- 
thing that  she  has  taken  by  mouth.  Constant  vertigo  and  palpitation, 
with  epigastric  pain,  ha\e  been  her  complaints. 

On  examination,  the  heart's  apex  was 
found  one  inch  outside  the  midclavicular 
line  in  the  fifth  space.  There  was  a  pre- 
systolic thrill  and  murmur  at  the  apex.  The 
sounds  were  very  irregular,  and  at  times 
amounted  to  delirium  cordis.  The  pul- 
monic second  sound  was  sharply  accentu- 
ated. At  times  a  systolic  murmur  was 
heard,  following  the  very  sharp  first  sound 
at  the  apex.  As  is  shown  in  the  accom- 
panying chart  (Fig.  124)  many  heart-beats 
failed  to  reach  the  wrist.*  There  ^^•ere  fine 
crackling  rales  at  the  base  of  both  lungs, 
especially  on  the  left  side. 

The  abdomen  was  tender  and  rii^id  in 
the  right  hypochondrium,  and  dulness  ex- 
tended two  inches  below  the  costal  margin; 
no  edge  was  felt.  Blood  and  urine  nor- 
mal. 
Despite  the  extreme  rapidity  and  irregularity  of  the  heart,  there  was 
no  cyanosis  or  orthopnea. 

Discussion. — The  essential  features  here  are  the  tuberculous  family 
history,  the  "fainting  fit,"  and  the  present  condition  of  the  heart. 

The  latter  shows  all  the  e\'idences  of  mitral  stenosis  rather  poorly 
compensated.  Proljably  she  has  to  thank  this  heart  trouble  for  lier 
freedom  from  tuberculosis. 

To  what  should  we  attrilnite  tlie  attack  of  coma?  In  manv  respects 
it  resembles  an  liystcric  attack.  Patients  \\ho  faint  very  seldom  do 
so  as  the  result  of  ^•al^■ular  heart  disease,  although  there  is  no  symptom 
except  "jjain   al)out  the  heart,"  wliich  so  often  alarms  a  patient  aljout 

'  In  this  chart  the  line  immcfliately  aljovc  that  rej;rcscnling  the  pulse  stands  fi)r  the 
numhtr  <>i  heart-beats  counted  at  the  apex. 


124. 


COMA  495 

his  cardiac  condition.  Of  the  numerous  patients  who  have  consulted 
me  believing  that  they  had  heart  trouble  because  of  the  occurrence  of 
"fainting  fits,"  I  have  never  found  heart  disease  in  a  single  case.  The 
sufiferings  of  this  patient  are,  therefore,  all  the  more  interesting.  Care- 
ful inquiry  into  her  pre^'ious  histor\'  showed  that  she  had  had  similar 
attacks  in  childhood,  and  had  always  had  a  decided  tendency  toward 
hysteria.  In  view  of  this  it  is  probably  true  to  say  that  her  heart  disease 
was  only  a  contributing  cause  of  her  "fainting  fits." 

It  must  not  be  forgotten,  however,  that  in  cases  of  mitnil  stenosis  a 
thrombus  often  forms  in  one  of  the  left  auricular  appendages,  whence 
a  bit  is  detached  and  carried  to  the  brain,  producing  embolic  hemi])lcgia. 
Possibly  a  minute  embolus  or  a  group  of  such  emboli  might  produce  a 
"fainting  fit"  without  paralysis,  but  this  conjecture  is  so  far  wholly 
unsupported. 

Outcome. — The  patient  was  gi^'en  I  grain  of  morphin  subcutane- 
ously  and  fed  on  milk  and  lime-water  in  small  amounts.  The  bowels 
were  mo\"ed  by  small  doses  of  calomel,  followed  by  a  suds  enema. 

On  the  fourteenth  of  IMay  the  heart-beats  all  reached  the  ^\■rist. 
On  the  twenty-third  she  was  able  to  walk  about,  and  had  no  complaints. 

Diagnosis. — Alitral  disease  (and  hysteria?). 

Case  261 

A  club  ^^•aite^  forty  years  old  has  been  at  work  as  usual  during  the  last 
five  days,  as  is  learned  from  the  manager  of  the  club  where  he  was 
employed.  He  was  first  seen  August  7,  1907.  He  has  done  no  hea\  y 
work,  and  nothing  is  known  of  his  |)rc\ioiis  history.  It  has  been  noticed 
that  his  color  is  ])oor,  and  he  has  expressed  a  fear  that  he  might  ha\e  a 
breakdown.  Night  Ijcfore  last  he  had  an  attack  of  dys])nca,  from 
which  he  recovered,  howe\er,  without  medical  attendance.  The  next 
day  he  did  his  work  as  usual,  but  seemed  irritable  and  rude,  so  that  he 
was  warned  by  the  manager.  This  morning  at  5  o'clock  he  was  fcnmd 
Iving  on  tlie  grass  outside  the  club.  He  said  that  he  went  out  there  to 
get  tlie  air.  He  seemed  very  short  of  i)reath,  ])ut  ^valke(l  to  the  ])ovch 
and  sat  down.  On  his  way  thence  to  the  hos])ital  he  ])ecamc  uncon>cious, 
and  at  the  time  of  his  entrance  was  almost  moribund. 

His  nutrition  was  excellent,  his  color  dusky.  The  licart's  apex  ',vas 
in  the  anterior  axillary  line,  in  the  sixth  s])acc.  The  sounds  were  \lt\- 
irregular  in  force  and  rhythm;  no  murmurs  were  licani.  Tracheal 
rales  were  so  loud  as  to  make  examination  of  the  heart  aiul  hnig>  \er\' 
(lifficuit.  Rcsi)iration  was  \ery  ra])i(l  and  irregular.  Tlie  li\er  secnicd 
to  be  sliirlitlv  enlarged. 


496  DIFFERENTIAL   DIAGNOSIS 

Outcome. — The  patient  died  within  a  few  hours.  Autopsy  showed 
chronic  endocarditis  of  the  mitral  \alve,  with  mitral  stenosis;  general 
arteriosclerosis;  hypertrophy  and  dilatation  of  the  heart;  hydrothorax; 
hydropericardium ;   cicatrices  in  the  liver. 

Discussion. — Why  was  this  patient's  death  so  sudden?  The  vast 
majority  of  cardiac  cases  die  in  their  beds  after  prolonged  periods  of 
dropsy  and  dyspnea.  Now  and  then  a  case  either  of  the  valvular  type 
(chronic  endocarditis),  of  the  arteriosclerotic,  or  of  the  syphilitic  types 
dies  suddenly. 

In  a  number  of  such  cases  no  coronary  disease,  no  pulmonary  em- 
bolism, and  no  other  sufficient  cause  for  sudden  death  can  be  found  post- 
mortem. 1  ha\e  seen  so  many  fruitless  examinations  of  this  sort  that  I 
no  longer  count  on  the  pathologist  to  explain  by  mechanical  causes  the 
sudden  death  in  cardiac  cases. 

Some  ultramechanical,  ]jerhaps  some  chemical,  explanation  must  be 
sought. 

Diagnosis. — Chronic  valvular  disease.  Sudden  heart  failure  from 
unknown  cause. 

Case  262 

An  Irish  housemaid  of  twenty-fi\e  was  seen  November  30,  1909. 
The  pre\ious  morning  she  had  seemed  perfectly  well  and  in  good  spirits. 
At  9  P.  M.,  November  29th,  she  suddenly  became  unconscious  and  fell 
to  the  floor,  though  her  brother  caught  her,  so  that  her  head  did  not 
strike.  After  this  she  \omited  several  times  without  regaining  con- 
sciousness. 

This  morning  she  roused  enough  to  moan  and  complain  of  severe 
headache,  but  soon  lapsed  into  coma  again. 

Examination. — Temperature,  101.6°  F.;    pulse,  no;  respiration,  22. 

Blood-pressure,  245  mm.  Hg.  Leukocytes,  28,000.  Urine  clear, 
acid,  io2c;  very  large  trace  of  albumin;  no  sugar.  Sediment  negative. 
Left  \)w\)\\  slightly  larger  than  right.  Both  react  sluggishly  to  light. 
Left  arm  and  leg  mo\ed  but  little  on  sensory  stimulation.  Babinski's 
reaction  on  the  left.     Knee-jerks  and  Achilles  jerks  absent. 

Physical  examination  was  otherwise  negati\-e. 

Lumbar  puncture  was  done,  and  blood-tinged  serous  fluid  spurted 
nearly  a  foot  through  the  needle.  The  sediment  of  this  fluid  showed 
no  excess  of  leukocytes  and  no  organisms  in  co\-er-sli]^  or  culture.  \'ene- 
section  gave  no  relief. 

Fundus  examination  showed  double  optic  neuritis. 

Discussion.— Coma,    leukocytosis,    fever,    and    hy])ertension  with 


COMA 


497 


pupillary  inequality  and  apparently  a  left  hemiplegia  are  the  essentials 
of  this  case. 

The  negative  character  of  the  spinal  fluid  is  sufficient  to  exclude 
meningitis. 

Diagnoses  of  uremia  made  under  these  conditions  always  turn  out 
wrong.     The  reasons  for  this  I  have  discussed  more  fully  on  p.  509. 

The  content  of  the  spinal  fluid  makes  syphilis  unlikely,  especially 
in  a  girl  with  no  previous  history  or  lesion  suggesting  that  disease. 

Apoplexy,  using  this  old  term  to  include  cerebral  hemorrhage, 
thrombosis,  or  embolism,  with  or  without  softening,  is  practically  un- 
known in  a  girl  of  this  age  so  long  as  the  heart  is  negative. 

The  double  optic  neuritis  with  the  ver\'  high  blood-pressure  and 
the  normal  heart  points  strongly  toward  cerebral  tumor. 

Outcome.— The  patient  died  suddenly  of  respiratory  failure  De- 
cember 2d.  The  temperature,  pulse,  respiration,  and  leukocyte  count 
remained  practicall}'  as  at  entrance.  After  lumbar  i)uncture  she  mo\'ed 
all  parts  of  her  body  freely,  complained  of  headache,  and  answered  a 
few  questions  clearh'  and  with  comprehension. 

It  was  learned  later  that  she  had  had  several  attacks  of  vomiting 
during  the  past  summer,  and  that  her  eye-sight  had  not  been  good. 

Diagnosis. — Cerebral  tumor  (?). 


498 


DIFFERENTIAL    DIAGNOSIS 


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Causes  of  Convulsions 


1.  ECLAMPSIA  (PUERPERAU 

2.  INFANTILE  SPASM 

3.  ALCOHOLISM 

■l^^H^HH^B^^^iHI^^^i^^BB^B^BB   544 
UREMIA  ^^^^IH^H^^^HBHIH 

6.  HYSTERIA       HJ^^l^H  108 

7.  MENINGITIS    Hi  28 


r)()0 


TT 


CHAPTER  XVI 
CONVULSIONS 

Case  263 

An  Irish  longshoreman  of  fifty  entered  the  hospital  November  17, 
1907.  He  has  been  a  steady,  hard  drinker  for  many  years,  but  denies 
venereal  disease,  and  has  been  otherwise  well.  Four  years  ago,  he 
says,  he  had  a  fit,  which  lasted  twenty  minutes;  nothing  of  the  sort 
has  occurred  since.  All  last  week  he  drank  hard.  He  spent  Saturday 
night  at  the  Salvation  Army  rooms.  On  Sunday, 
November  17th,  while  attending  a  Salvation  Army 
meeting,  he  became  unconscious. 

When  examined  at  5:25  p.  m.,  November  17th, 
he  was  still  unconscious  and  in  convulsions,  at  times 
confined  to  the  right  side,  later  general,  and  succeed- 
ing each  other  without  intermission. 

There  was  a  deep,  bleeding  cut  on  the  chin,  and  a 
shifting  strabismus  of  the  eyes.  Marked  hyperreson- 
ancc  of  the  lungs  made  it  impossible  accurately  to 
estimate  the  size  of  the  heart.  Its  sounds  were  also 
obscured  by  snoring  rales,  but  the  arteries  showed  no 
evidence  of  degeneration,  and  physical  examination  was 
gencrallv  ncgati\-c.  For  temperature,  see  the  accom- 
l^anving  chart  fFig.  125).  The  blood  showed  nothing 
abnormal. 

The  urine  was  pale,  102 t  in  specific  gravity,  with 
the  slightest  possible  trace  of  all)umin.  One  finely 
granular  cast  was   found   in   the  sediment. 

l^)lood-])ressure  was  125  mm.  Hg. 

Discussion. — In  the  absence  of  any  ()1)\ious  localizing  brain  symp- 
toms or  signs,  e])ilepsv  is  naturally  our  first  thought,  especiall}'  as  wc 
know  that  an  attack  of  epilepsy  is  apt  to  be  precij)itated  by  acute 
alcoiiojism.  But  if  we  are  to  take  the  history  on  its  face  xahi*.'  and 
understand  that  there  has  been  ])ut  one  attack  ])rc\i()u^-ly.  it  >tt.'in> 
unHkely  that  a  man  of  this  age  would  become  e])ik'])tic  -o  rfccntl}-. 

501 


Hk'-    i-\>-      Chart  of 
case  2(>x. 


502  DIFFERENTIAL   DIAGNOSIS 

In  the  urinary  examination  ([uoted  nothing  is  said  about  sugar,  but 
e\'en  if  it  were  known  to  be  present,  its  quantity  cannot  be  large  in  view 
of  the  specific  gravity  of  the  urine,  and  it  may  be  further  stated  that, 
although  diabetes  may  ])roduce  convulsions,  it  practically  ne\er  does 
so  "out  of  a  clear  sky'' — that  is,  in  patients  who  have  not  previously 
known  themsehes  to  be  ill  or  suffered  any  of  the  cardinal  symptoms  of 
diabetes. 

Meningitis  might  begin  in  this  way,  and  the  chart  is  consistent  there- 
with, but  a  knowledge  of  the  results  of  lumbar  puncture  would  be  neces- 
sary before  any  such  diagnosis  could  be  made,  since  we  have  none  of 
the  ordinary  manifestations  of  meningitis  (cer\ical  rigidity,  Kernig's 
sign,  squints  and  pupillary  changes,  headache,  vomiting,  and  delirium). 

Of  lead-poisoning,  of  dementia  paralytica,  brain  tumor,  or  abscess 
— all  of  which  might  cause  similar  con\'ulsions — we  have  no  evidence 
either  in  the  history  or  in  the  physical  examination.  Hysteria  and 
trauma  need  not  be  considered. 

With  the  exclusion  of  these  alternati\'es  the  most  reasonable  hypothesis 
remaining  is  that  the  alcohol  is  the  source  of  the  trouble.  From  con- 
\ersations  with  physicians  who  attend  the  Saturday-night  drunks  in  city 
prisons  my  own  more  limited  experience  of  *'rum  fits"  is  fortiiied  in 
making  the  following  division  into  three  groups: 

(a)  An  alcoholic  debauch  may  make  a  person  hysteric  and  so  pre- 
cipitate hysteric  convulsions. 

(b)  Alcohol  may  bring  on  one  of  the  regular  epileptic  attacks  in  a 
patient  already  suffering  from  that  disease. 

(c)  A  true  "rum  fit"  may  be  produced  by  alcohol  in  a  person  not 
epileptic  or  hysteric.  These  fits  are  presumably  due  to  the  cerebral 
changes  ("wet  brain,"  vascular  crises)  produced  by  alcohol. 

The  present  case  seems  to  belong  to  the  third  group. 

Outcome. — The  patient  was  bled  about  20  ounces,  and  an  equal 
amount  of  saline  solution  was  injected.  About  10  p.  m.  he  regained 
consciousness  and  remained  thereafter  practically  normal.  Later  he 
admitted  that  liis  ])resent  trouble  began  on  the  second  night  of  his  last 
spree.  The  bystanders  say  that  there  \\"as  no  cry  at  the  time  he  fell 
and  the  sphincters  were  not  relaxed.  He  was  discharged  well  on  the 
twenty-second. 

Diagnosis. — Alcoholism. 

Case  264 

A  housemaid  of  twent\ .  of  good  family  historv  and  j)ast  histor}-, 
entered  the  hospital  February  12,  1908.     She  has  been  irregular  in  her 


CONVULSIONS 


503 


menstruation  for  the  past  six  years,  and  has  been  subject,  during  that 
period,  to  frequent  severe  left-sided  headaches  and  to  attacks  of  uncon- 
sciousness. These  attacks  are  apt  to  occur  on  the  first  day  of  menstrua- 
tion, but  they  may  come  in  the  middle  of  the  intermenstrual  period. 
She  has  considerable  pain  in  the  lower  abdomen  during  the  first  two 
days  of  menstruation,  otherwise  the  function  is  not  al^normal.  During 
her  attacks  of  unconsciousness  she  falls,  but  sometimes  can  get  up  and 
steady  herself  by  taking  hold  of  something.  She  is  then  apt  to  become 
violent,  going  out  of  her  head,  frothing  at  the  mouth,  often  gripping 
her  throat  with  her  hands,  sometimes  bleeding  from  the  mouth  and 
nose.  She  has  never  injured  herself  nor  passed  urine  during  an  attack. 
The  attacks  last  from  a  few  minutes  to  a  few  hours. 

Her  last  menstruation  ceased  five  days  ago.  Two  days  ago,  while 
sweeping,  she  felt  dizzy,  fell  down,  and  sa}-s  she  remembers  no  more 
until  she  was  seen  at  the  hospital.  From  her  friends  it  was  learned 
that  after  her  fall  she  was  put  to  bed,  where  she  threw  herself  about 
and  talked  incoherently  all  day.  At  7  in  the  evening  she  apparently 
came  to,  and  was  taken  home  from  her  ])lace  of  work  at  11  p.  m.  She 
again  became  unconscious  and  lay  still  in  bed  with  limbs  rigid. 

Yesterday  she  awoke  and  said  she  felt  well.  She  \\ent  to  work 
at  8  o'clock  in  the  morning,  but  an  hour  later  again  fell  unconscious 
and  rigid  and  remained  so  until  this  morning  at  6,  when  she  was  partially 
aroused  by  an  enema  of  soapsuds,  but  became  again  unconscious  after 
twenty  minutes.  She  has  taken  no  food  for  four  days,  according  to 
her  own  statement.  She  has  been  very  constipated  for  years.  During 
these  attacks  she  says  her  feet  are  apt  to  swell,  but  at  other  times  they 
arc  never  swollen. 

Physical  examination  showed  a  well-nourished  girl,  herpes  on  her 
lips,  dozing  most  of  the  time,  aj)])arentl}'  rational  when  aroused,  but 
a])athctic  and  complaining  of  hcadaclic  and  abdominal  pain. 


lig.  126. — 1  )ia<ir;iininatir   n-prcsciilation    of  upper  nudian  im  isnrs  in   i  aso   204.      Tiny 
an-  slI  far  aj)an  and  arc  malformed,  curving  toward  cai  ii  oiIk  r  at  the  ends. 

The  ui)])cr  and  median  incisor  tt'ctli  arc  malformed.  I'he  othtr 
teeth  are  in  fair  condition.  (Sec  Fig.  126.)  Tlie  pu])ils  are  dilated 
and  react  sluggishl}-  to  light  and  distance.  I'he  \ault  of  tlie  palate 
is  M'r\'  liigli  and  narrow.  She  is  a  mouth-breather.  The  licart's  apex 
is  in  the  fourth  inters])a('e.  one-liaH"  inch  outside  the  nu'(lcla\"iciilar  line. 
The  soun(l>  are  of  good  (|ualit\-.     At  the  apex  there  i>  ;i  I'nul  -}>t(ilic 


504  DIFFERENTIAL   DIAGNOSIS 

murmur,  heard  clearly  in  the  axilla,  faintly  in  the  pulmonary  area. 
This  murmur,  or  a  similar  one,  is  heard  in  the  tricuspid  area,  and  there 
it  seems  to  be  of  a  higher  pitch  and  different  quality.  In  the  tricuspid 
area  the  first  sound  is  much  louder  and  sharper  than  in  the  mitral  area. 
The  pulmonic  second  sound  is  slightly  accentuated.  There  is  a  systolic 
venous  pulse  in  the  neck.  The  radial  pulses  are  not  in  any  way  remark- 
able. The  abdomen  and  reflexes  are  not  abnormal.  Sensation  is 
apparently  normal. 

During  the  first  night  after  her  arrival  the  patient  complained  of 
headache  and  severe  abdominal  pain.  Half  an  hour  later  she  began 
to  grow  rigid  and  clutched  the  blankets  firmly.  She  then  became 
apparently  unconscious.  Her  pulse  was  76,  respiration  44.  When 
the  lighted  lamp  was  held  in  front  of  her  she  closed  her  eyes  more  tightly. 
When  they  were  forcibly  opened,  the  balls  were  found  to  be  rolled  up, 
and  she  turned  her  head  as  if  to  avoid  the  light.  The  rigidity  of  the 
arms  could  be  overcome,  though  with  difficulty.  It  seemed  to  be 
partially  voluntary,  A  pin  could  be  passed  through  a  fold  of  the  skin 
without  causing  any  change  of  expression  or  any  motion. 

After  half  an  hour  of  this  rigidity  the  patient  became  again  sensiti^■e 
to  pain  and  would  reply  to  questions. 

On  the  twenty-first  she  complained  of  a  severe  headache,  which 
immediately  disappeared  under  the  ethyl  chlorid  spray.  The  attention 
then  became  concentrated  on  the  abdominal  pain.  After  that  the 
headache  did  not  return  and  she  said  the  treatment  cured  her. 

Discussion. — The  symptoms  in  this  case  and  the  description  of  the 
attack  remind  us  very  strongly  of  hysteria.  Two  other  possibilities, 
however,  must  first  be  considered. 

Can  the  malformation  of  the  incisor  teeth  be  interpreted  as  a  lesion 
of  congenital  syphilis  and  the  convulsions  be  also  due  to  that  disease  ? 
This  is  very  improbable,  for  aside  from  these  attacks  there  is  nothing 
in  the  patient's  condition  or  history  to  suggest  syphilis,  a  disease  which, 
in  its  congenital  form,  almost  always  appears  earlier  than  in  the  twentieth 
year.  The  nature  of  the  attack,  moreover,  is  not  at  all  characteristic 
of  cerebral  syphilis,  of  which  more  anon.  The  malformed  teeth  are 
not  of  the  Hutchinsonian  tvpe. 

Can  the  tricuspid  regurgitation,  evidenced  by  systolic  venous  pulsa- 
tion in  the  neck,  the  swollen  feet,  and  the  murmur  in  the  tricuspid  area, 
account  for  the  attack?  In  ans\\ering  this  question  it  must  first  be 
noticed  that  the  tricuspid  regurgitation  must  be  slight  if,  indeed,  it 
exists  at  all  in  any  ])athologic  sense.  Many  ol)ser\-ers  believe  thac  a 
slight  degree  of  tricuspid  regurgitation  is  physiologic.     As  a  result  of 


CONVULSIONS 


D"3 


various  strains  or  accidents  we  may  conceive  that  this  physiologic 
reflux  is  more  or  less  exaggerated,  but  one  can  hardly  be]ie\'e  that  its 
effects  would  be  so  disproportionately  concentrated  upon  the  brain 
as  to  produce  convulsions  without  bringing  about  any  more  ob\ious 
stasis  in  the  other  internal  organs. 

With  the  exclusion  of  these  two  possibilities  we  may  conclude  that 
the  attack  was  due  to  hysteria.  The  present  case  exemplifies  many  of 
the  characteristic  signs  by  which  hysteric  convulsions  have  traditionally 
been  differentiated  from  those  due  to  the  other  causes  discussed  in  this 
chapter.     Such  characteristics  are: 

(a)  The  absence  of  deep  coma. 

(b)  The  semivoluntary  and  semiconscious  nature  of  the  motions 
(e.  g.,  such  as  to  pre^•ent  her  hurting  herself  in  falling,  grasping  motions, 
talking,  resistance  of  efforts  to  open  the  eyelids). 

(c)  The  absence  of  any  biting  of  the  tongue,  any  relaxation  of  the 
sphincters,  presjmsmic  cry,  or  aura. 

These  characteristics  hold  good  in  probably  the  large  majority  of 
hysteric  cases,  but  it  must  be  realized  that  these  and  all  the  other  signs 
by  which  we  have  sought  to  difjerentiate  hysteric  jrom  epileptic  convul- 
sions may  jail  us.  Attacks  which,  on  the  whole,  must  Ije  judged  h}-steric 
may  occur  in  the  night  during  sleep,  may  be  accompanied  by  lilting  of 
the  tongue  and  all  the  ordinary  evidences  of  an  epileptic  fit.  I  have 
recently  known  such  a  case  in  which  the  cause  of  the  spasms  was  found 
to  reside  in  a  partly  subconscious  knot  of  morbid  ideas,  acquired  in 
childhood,  reenforced  by  the  abnormal  conditions  of  a  girls'  boarding- 
school,  and  finally  removed  as  a  result  of  psycho-analysis  and  Freud's 
cathartic  method.  Attacks  which  can  be  thus  abolished  must  be 
recognized,  I  sujipose,  as  belonging  to  the  hysteric  group. 

The  reasonable  conclusion  is  that,  in  doubtful  cases,  we  cannot  rely 
upon  the  ])recise  nature  of  the  movements  or  on  individual  features  of 
attacks  to  differentiate  hysteria  and  e])ilepsy.  Only  by  a  study  of  the 
])ossible  causes  in  the  patient's  mental  life  and  by  the  therapeutic  test 
(/.  r.,  the  attempt  to  reni()\e  these  causes)  can  the  nature  of  the  malady 
be  determined.     This  is  in  line  with  Babinski's  c()nce])ti()n  of  hysteria. 

Diagnosis. — Hysteria. 

Case  265 

A  married  woman  forty-eight  years  old  entered  the  h{)s])ital  janr.an- 
I,  iQGcS.  Her  last  menstrual  period  was  in  the  preceding  Sci>k'i'nl)rr, 
and  she  has  ap])arently  readied  the  menopause.  She  lia>  had  ner\(nis 
])rostration   three  times,   tlie  last  time  two  years  aL:o.     Fi\e  da}s  ago 


5o6  DIFFERENTIAL   DIAGNOSIS 

she  was  taken  with  influenza  and  conlined  to  Ijcd.  She  was  first  seen 
by  her  physician  three  days  ago,  when  she  suddenly  collapsed  from 
"acute  heart  failure  "  and  jjain  in  the  back. 

The  doctor  found  her  much  exhausted,  pale,  very  dyspneic,  and 
])artially  stui)orous.  At  frequent  intervals,  three  times  within  an  hour, 
the  pain  in  her  back  Ijecame  very  severe;  the  muscles  of  the  trunk  were 
rigid  and  all  the  muscles  of  the  body  twitched  convulsivel}-.  Xitro- 
glvcerin  afforded  much  relief.  The  next  day  the  paroxysms  of  jjain 
continued  and  she  lost  the  use  of  her  limbs.  For  twenty-four  hours 
she  had  retention  of  urine,  and  40  ounces  were  tmally  drawn  by  catheter. 
Within  the  last  twenty-four  hours  the  use  of  her  limbs  has  in  part  re- 
turned, but  the  pain  in  her  back  continues  and  is  sharp  when  she  tries 
to  move.  The  attacks  of  ]jain  are  still  accompanied  at  times  by  muscular 
twitching. 

When  first  seen,  her  tem|)erature  was  102.2°  F.  During  the  first  day 
in  the  hospital  it  was  100°  F. 

Visceral  examination  was  negative,  as  were  reflexes,  the  urine,  and 
the  blood.  Blood-pressure,  135  to  140.  The  ])harynx,  larynx,  and 
trachea  were  markedly  iniected,  and  there  was  herpes  on  the  lips. 

By  the  fifth  of  January  she  was  much  better  and  able  to  be  up,  but 
was  very  unwilling,  even  on  the  thirteenth,  to  leave  the  hospital.  On 
the  thirtieth  she  was  able  to  do  so. 

Discussion. — There  are  some  indications  of  an  acute  infection 
here,  especially  the  red  throat  and  the  herpes  on  the  lips.  It  is  a  very 
familiar  fact  that  in  children  the  onset  of  acute  infectious  diseases  often 
produces  a  typical  epileptiform  convulsion.  It  seems  possible  that  the 
])resent  attack  may  be  the  equivalent  of  such  a  convulsion,  modified 
by  the  age  of  the  patient,  although  the  precise  nature  of  the  infection  is 
unknown  ("influenza"). 

Some  facts  in  the  case,  however,  suggest  a  dift'erent  type  of  conNul- 
sion.  The  intense  ])ain  in  the  back,  the  rigidity  of  the  trunk  muscles, 
tlie  temporary  loss  of  ])Ower  in  the  limbs,  the  retention  of  the  urine,  are 
all  of  them  sym])toms  consistent  with  some  tyjje  of  organic  disease  of  the 
si)inal  cord  or  its  membranes.  The  difficulty  with  this  idea  is  that 
closer  scrutin}-  of  the  symptoms  fails  to  find  any  arrangement  among 
them  corresponding  to  any  known  disease,  wliile  their  outcome  seems 
lo  show  that  no  ])crmanent  lesion  has  occurred  in  the  central  Jiervous 
svstem. 

By  the  results  of  ])hysical  examination  it  is  ])Ossible  to  exclude 
organic  brain  disease,  sucli  as  meningitis,  dementia  paralytica,  abscess 
or  tumor,  and  apo])lex}'.     There  is  no  evidence  of  poisoning  Ijy  lead 


CONVULSIONS 


507 


nor  of  any  organic  disease  of  the  heart  and  kidney.  There  has  appar- 
entl}-  been  no  pre\ious  attack  resembling  the  present  one,  and  an  e]>ilepsy 
beginning  at  forty-eight  is  always  an  improbable  diagnosis. 

In  view,  therefore,  of  the  negative  result  of  physical  examination 
directed  to  re\eal  the  ordinary  organic  causes  of  con\ulsions  we  ma\- 
conclude  that  this  attack  is  of  functional  type,  ordinarily,  though  some- 
what loosely,  designated  as  "hysteria."  This  diagnosis,  however,  does 
not  end  our  study  of  the  actual  nature  of  this  attack. 

Two  points  are  of  especial  interest  in  relation  to  this  ];articular 
example  of  the  vague  type  of  spasms  known  as  "hysteric"  or  'func- 
tional." We  have,  in  the  first  place,  to  consider  the  possible  influence 
of  the  psychic  elements  which  may  have  l)een  introduced  quite  uncon- 
sciously by  her  physician  and  friends.  It  will  be  noted  that  she  is  said  to 
have  suddenly  "collapsed"  as  a  result  of  "acute  heart  failure."  Xow 
these  phrases  ha\e  a  very  great  effect  ujjon  the  mind  of  a  patient  and 
thereby  upon  his  symptoms.  We  often  see  what  a  great  benefit  may 
be  produced  in  a  jmtient  when  we  jjcrsuade  him  that  his  headache  is 
not  in  "the  base  of  his  brain,"  but  merely  in  the  na])e  of  his  neck,  or 
that  the  pain  in  the  left  side  of  his  chest  is  not  "around  the  heart," 
but  merely  in  the  stomach  or  in  the  ribs. 

A  corresponding  aggravation  of  symptoms  is  pretty  sure  to  follow 
if,  by  chance,  such  phrases  as  "collapse"  or  "acute  heart  failure"  are 
let  loose  in  the  patient's  vicinity,  whether  they  are  from  the  jjatient's 
own  lips  and  merely  corroljorated  by  the  physician,  or  whether  the 
j)atient  overhears  them  in  the  conxersation  of  relati\es  or  ])ystanders. 
Particularly  in  their  early  stages,  functional  attacks  may  be  greatly 
relieved  if  we  call  a  spade  a  spade,  rather  than  an  agricultural  instru- 
ment. To  make  light  of  symj^toms  which  our  ])liysical  examination 
assures  us  are  not  of  serious  imj)ortance  may  shorten  by  man}-  da}s  the 
j)aticnt's  illness,  while,  on  the  other  hand,  suggestions  con\eyed  b}'  a 
gra\e  and  serious  ex])ressi()n  rellecled  from  the  doctor's  face  to  the 
family,  by  the  terminology  used  or  pcnniltcd  by  the  doctor,  or  b\-  the 
nature  of  the  remedies  em])lo\e(l.  may  greatly  aggra\ate  and  prolong 
the  patient's  sulTerings.  For  example,  I  rememl)er  a  case  of  po-t- 
operatixe  ])leurisy  in  which  the  i)atient,  who  was  Jiigh  strung  and  ])retl\ 
well  tired  out  i>re\ious  to  the  operation,  began  to  breathe  \cry  rapid!}, 
so  that  the  nur>e  in  charge  brought  in  a  can  of  oxygen  and  adniini^teri'd 
it  at  regular  inter\als.  The  j)atient  took  for  granled  that  thi^  \\a> 
done  1)\'  the  doctor's  orders.  lUit  hi>  ])re\ious  hos])ital  experience,  in 
cc)nnection  with  an  appendix  operation,  had  led  him  to  a--ociaU'  the 
arrival  of  the  oxvtren  ca.n  with  the  most  serious  and  e\en  urniinal  -lauc- 


5o8  DIFFERENTIAL   DIAGNOSIS 

of  disease.  He  had  noticed  that  pretty  soon  after  the  oxygen  can  was 
carried  into  a  patient's  room  the  patient  himself  was  carried  out  dead. 

As  a  result  of  putting  two  and  two  more  or  less  unconsciously  together 
in  this  way,  my  jmtient  became  greatly  alarmed  about  himself,  was 
hardly  able  to  breathe,  and  totally  unable  to  sleep.  Soon  after,  his 
physician  came  in,  was  greatly  surprised  at  the  sight  of  the  oxygen  can, 
promptly  ordered  it  out,  and  irritably  asked  the  nurse,  in  the  patient's 
hearing,  what  on  earth  she  ''had  brought  that  thing  in  for  when  there 
was  not  the  slightest  need  for  it."  The  patient  soon  afterward  went 
to  sleej),  and  awoke  next  morning  much  improved.  He  afterward 
confessed  to  the  writer  how  the  sight  of  the  oxygen  can  had  affected 
him,  and  how  profoundly  its  removal  had  relieved  him. 

The  other  point  of  interest  in  this  case  is  the  relief  by  nitroglycerin. 
In  Pal's  book  on  \'ascular  Crises,  to  which  I  have  already  referred,  he 
shows  that  any  type  of  vascular  spasm,  cerebral,  cardiac,  pulmonary, 
abdominal,  or  peripheral,  may  be  relieved  by  the  administration  of 
nitroglycerin,  and  uses  the  fact  of  such  relief  as  corroborative  evidence 
of  the  nature  of  the  attack.  Now  this  patient  is  apparently  at  the  meno- 
pause, a  period  in  which  disturbances  of  vasomotor  balance  are  notori- 
ously frequent,  manifold,  and  annoying.  Is  it  not  possible  that  this 
attack  was  of  the  nature  of  a  \ascular  crisis  induced  by  the  onset  of  an 
acute  infection  at  an  especially  sensitive  period  of  life?  In  the  present 
state  of  our  knowledge  no  definite  answer  can  be  given  to  this  question. 

Diagnosis. — Hysteria. 

Case  266 

An  unmarried  woman,  thirty-eight  years  old,  was  seen  in  consulta- 
tion at  8  a.  m.,  September  26,  1909. 

She  had  suffered  all  her  life  from  periodic  headaches  occurring 
e^"ery  two  to  four  weeks,  more  especially  at  the  time  of  menstruation. 
Aside  from  these  attacks,  she  had  never  been  sick,  and  seemed  to  be 
vigorous  in  every  respect.  On  the  nineteenth  of  May  she  went  to  bed 
with  one  of  her  regular  headaches,  so  it  seemed.  During  the  day  she 
had  seemed  as  well  as  usual.  About  i  o'clock  in  the  morning  her  sister, 
who  slept  in  the  same  room  with  her.  was  aroused  by  some  curious 
sound,  and  found  the  patient  unconscious  and  in  a  convulsion.  When 
seen  in  consultation  at  8  o'clock  a.  m.,  she  was  conscious,  but  ver\' 
drowsy  and  heavy.  Between  i  a.  m.  and  8  A.  M.  she  had  had  six  general 
tonic-clonic  convulsions,  fi\e  of  them  accompanied  by  complete  loss 
of  consciousness,  each  lasting  about  a  minute,  and  followed  by  ])rofound 
relaxation  with  deej)  relaxed  Ijreathing. 


CONVULSIONS 


509 


Physical  examination  of  the  chest  and  abdomen  was  negative.  The 
reflexes  were  all  somewhat  exaggerated,  especially  on  the  left  side,  and 
at  times  Babinski's  reaction  could  be  elicited  on  the  left.  The  pupils 
were  moderately  dilated,  the  left  larger  than  the  right,  and  responded 
rather  sluggishly  to  light  stimulus.  When  conscious,  she  was  aware 
of  no  pain,  and  although  she  had  been  more  or  less  nauseated,  there 
had  been  no  vomiting.  The  urine  drawn  by  catheter  showed  sj)ecific 
gravity  of  1014,  0.125  per  cent,  of  albumin,  a  moderate  number  of 
hyaline  casts,  some  with  granules  or  cells  adherent.  There  was  no 
edema  anywhere.     The  blood-pressure  was  138  mm.  Hg. 

The  convulsions  were  usually  preceded  by  some  shaking  of  the  left 
hand,  extending  thence  to  the  foot  and  leg,  and  then  becoming  general. 
The  eye-grounds  were  not  examined.  The  temperature  was  101.3°  F.; 
pulse,  100  between  convulsions,  becoming  rapid  and  feeble  during  and 
after  them. 

The  blood  showed  16,000  white  cells,  81  per  cent,  of  which  were 
polynuclear. 

The  bowels  were  mo\ed  by  enema,  and  showed  nothing  of  impor- 
tance in  the  intestinal  evacuation. 

Discussion. — When  I  saw  this  patient,  a  diagnosis  of  uremia  had 
already  been  made  by  the  attending  physician.  Against  this  I  imme- 
diately rebelled  in  my  own  mind,  e\'en  in  advance  of  accurate  physical 
examination.  For  this  prejudice  I  had  two  reasons:  First,  I  had 
recently  heard  one  of  the  wisest  and  most  experienced  clinicians  in  the 
world  say  that  he  had  never  known  a  diagnosis  of  uremia,  made  when 
the  patient  was  seen  for  the  first  time  in  coma,  to  turn  out  correct.  By 
this  he  meant  that  the  correct  diagnoses  of  uremia  are  those  made  in 
chronic  cases,  not  those  made  in  ])atients  who,  out  of  a  clear  sky,  with- 
out any  ])revious  complaints,  haxc  suddenly  fallen  in  coma  or  con\'ul- 
sions. 

My  second  reason  was  that  in  the  study  of  1500  postmortem  examina- 
tions made  at  the  Massiichusetts  General  Hospital  within  the  last  ten 
\ears  I  Imve  l)een  unable  to  find  a  single  case  in  which  the  diagnosis 
of  "acute  uremia"  had  been  confirmed  at  auto])sy.  I  found  many  in 
which  this  diagnosis  was  shown  to  lie  erroneous. 

This  mistake  results,  no  doubt,  because  nearly  all  cases  in  which 
coma  or  conxulsions  suddenly  su])er\"ene,  show  albuminuria  and  casts. 
sometimes  in  great  alnmdancc.  This  is  true  whatrccr  the  cdusc  of  the 
seizure. 

Nocturnal  ej)ik'])sy  witli  status  epih^ptirv.';  seemed  wry  im])rol)able 
because  the  ])atient's  sister  had  been  in  the  habit  of  sleeping  in  the  s;iine 


5IO  DIFFERENTIAL   DIAGNOSIS 

room  with  her  for  some  years,  and  had  never  known  of  any  similar 
attack,  nocturnal  or  diurnal. 

The  absence  of  any  j)revious  cardiovascular  or  renal  disease,  the 
normal  condition  of  the  heart  and  blood-pressure,  the  absence  of  any 
history  or  present  c\idence  of  syphilis,  made  apoplexy  and  vascular 
crises  somewhat  improbable. 

Cerebral  tumor  and  abscess  have  been  known  to  begin  or  rather  to 
show  themseh-es  for  the  first  time  with  symptoms  like  those  here  de- 
scribed, and  there  is  nothing  by  which  we  can  positively  exclude  these 
lesions.  We  should  expect,  however,  a  higher  blood-pressure.  Fundus 
examination,  which  was  not  made  in  this  case,  might  be  of  decided  assist- 
ance, since  the  A'ast  majority  of  cases  in  which  a  cerebral  tumor  produces 
convulsions  also  show  optic  neuritis  (choked  disk). 

What  is  the  significance  of  the  leukocytosis  here  present?  Experience 
has  shown  me  that  the  leukocyte  count  is  practically  valueless  as  a  source 
of  information  in  cases  involving  coma  or  convulsions.  Whatever  the 
cause  of  these  symptoms,  leukocytosis  is  practically  always  present. 
In  cerebral  hemorrhage,  for  example,  it  is  almost  constant.  In  this 
case,  therefore,  as  in  others,  I  disregarded  it. 

Utterly  in  the  dark  as  to  the  diagnosis,  it  seemed  to  me  possible 
that  some  light  might  be  shed  upon  it,  or  possibly  some  relief  given  to 
the  patient's  symptoms,  by  lumbar  puncture.  As  will  be  shown  by  the 
outcome,  this  puncture  turned  out  to  be  of  critical,  indeed.  I  think,  of 
life-saving,  importance.  Its  value  in  this  case  was  such  that  I  shall 
in  future  never  be  content  unless  it  is  done  in  every  doubtful  case  involv- 
ing coma  and  convulsions. 

The  fever  here  recorded  has  as  little  diagnostic  value  as  the  leuko- 
cytosis. It  is  in  nowise  indicative  of  an  infectious  process,  but  occurs 
with  equal  frequency  in  all  types  of  coma  and  in  all  diseases  producing 
con\'ulsions. 

Outcome. — A  needle  introduced  into  the  spinal  cord  drew  37  c.c. 
of  clear,  transj)arent,  colorless  fluid.  Of  the  cells  contained  within  the 
sediment  of  this  fluid  seventy-eight  per  cent,  were  polynuclear.  and 
both  within  and  without  the  leukocytes  a  diplococcus  was  seen  wliich 
corresponded  with  the  di])lococcus  of  epidemic  meningitis. 

Flexner's  antimeningitic  serum  was  injected  several  times.  The 
l)atient  made  a  com])]ete  reco^•ery.  although  for  a  few  hour<  on  the  sixth 
day  she  became  suddenly  and  comj)letely  blind.  The  attack,  ho\ve\er. 
left  no  untoward  efl'ccts  Ijcliind  it. 

Diagnosis. — Epidemic  meningitis. 


CONVLLSIONS 


Case  267 

A  plumber  of  sixty-two.  one  of  whose  children  died  of  consumption, 
had  been  an  intermittent  hard  drinker  for  many  years,  taking  rather 
more  of  late — sometimes  a  quart  of  whisky  a  day.  He  entered  the 
hospital  January  29,  1908.  Even.'  night  for  two  or  three  years  he  has 
filled  a  chamber  vessel  with  pale  urine  and  has  teen  seen  to  drink 
much  more  water  than  formerly.  He  has  had  no  headache,  no  cough, 
no  Nomiting,  but  has  belched  a  good  deal  of  late.  His  eye-sight  has  been 
good. 

At  2  o'clock  on  January  29th  he  had  a  convulsion  in  a  street  car, 
and  was  brought  at  once  to  the  hospital,  where  he  immediately  had  a 
second  convulsion,  after  which  he  was  very  restless, 
struggling  and  throwing  himself  about  on  the  table. 
At  first  he  said  nothing  and  did  not  answer  ques- 
tions, but  later  he  swore  profusely.  There  was  no 
odor  of  alcohol  or  of  acetone  on  the  breath.  The 
right  puj)il  was  larger  than  the  left;  both  reacted 
well  to  light  and  accommodation.  The  tongue  was 
\ery  dry  and  red.  No  enlargement  of  the  heart  was 
made  out,  and  there  seemed  to  be  no  accentuation  of 
either  second  sound.  Blood-pressure  was  1 70  mm.  Hg. 
The  artery  walls  were  palpable  and  tortuous.  The 
lungs  were  hyperresonant  throughout.  Breath-sounds 
were  accompanied  by  many  medium,  crackling  rales 
o\'er  both  lungs.  The  abdomen  was  held  somewhat 
rigidly,  but  nothing  abnormal  was  detected. 

During  this  examination  he  had  a  third  convul- 
sion lasting  about  three  minutes,  cjuite  e])ile])tiform 
in  ty})e,  with  coma.  The  course  of  the  temperature 
is  seen  in  the  accom])anying  chart  (Fig.  127). 

White  cells  were  16.500;    hemoglol)in,  80  j)cr  cent. 

The  urine  was  of  high  gra\ity.  with  a  \cry  slight  trace  of  albumin, 
but  no  casts  at  all. 

Discussion, — In  such  a  hard  drinkiT  the  (juestiou  of  "rum  lit-"' 
nui>t  be  entertained.  The  ])atient  has,  howexer.  no  odor  of  alcohol 
and  no  history  of  a  recent  increase  in  the  amount  of  alcohol  consutiud. 
This  is  not  an  acute  del)auch  of  the  Satunhniiight  type,  such  as  iTi;ikc- 
"rum  fits"  so  common  in  our  ])once  >tation'^.  It  i^  a  Iopl''  -^laii'l'iiL: 
liahit,  which  would  ])robabI\-  not  begin  to  produce  the--e  c-]iieial  L-i;e\t- 
at  the  aue  of  sixt\--two. 


512  DIFFERENTIAL   DIAGNOSIS 

The  condition  of  the  urine  is  not  characteristic,  but  the  history  of 
excessive  nocturia  and  the  high  blood-pressure  makes  us  suspect  chronic 
nephritis  as  the  ultimate  cause  of  this  attack.  When  the  lungs  are 
universally  hyperresonant,  it  is  very  difficult  to  make  out  the  size  of 
the  heart.  Hence  there  may  well  have  been  a  cardiac  hypertrophy 
in  this  case,  although  none  was  discovered. 

Of  the  organic  diseases  involving  the  brain  and  its  membranes,  we 
have  no  definite  evidence.  This  does  not  by  any  means  exclude  them, 
but  makes  it  impossible  for  us  to  move  any  nearer  toward  a  diagnosis 
of  any  one  of  them  until  further  signs  appear.  An  examination  of  the 
fundus  oculi  might  give  great  assistance,  likewise  lumbar  puncture. 

My  reasons  for  ignoring  the  diagnosis  ordinarily  made  under  these 
conditions — ;'.  e.,  acute  uremia — have  already  been  given  (see  p.  509), 
and  may  here  be  simply  summarized  by  saying  that  I  do  not  beheve  that 
any  such  condition  exists.     Uremia  is  a  chronic  affair. 

As  a  working  diagnosis,  therefore,  sufficient  to  guide  treatment  in 
the  emergency,  a  vascular  crisis  favored  by  the  underlying  nephritis 
seems  reasonable. 

Crackling  rales  were  to  be  heard  throughout  both  lungs  in  this  case. 
Their  significance  deserves  some  discussion.  Any  one  who  has  seen 
many  cases  of  sudden  coma,  with  or  without  convulsions,  must  have 
noticed  that  we  can  almost  always  hear  these  scattered  rales,  whatever 
the  nature  of  the  attack.  Their  number  and  the  extent  of  their  distri- 
bution seem  to  depend  upon  the  severity  of  the  attack  and  the  depth 
of  the  coma,  rather  than  upon  its  cause.  I  have  seen  them  in  sunstroke, 
alcoholic  and  narcotic  poisoning,  apoplexy,  brain  tumor,  plumbism, 
meningitis,  and  various  other  conditions,  with  or  without  a  fatal  issue. 
I  am  not  now  referring  merely  to  the  tracheal  rales  or  snoring  sounds 
attributable  merely  to  the  coma  which  prevents  the  patient  from  clearing 
the  throat  or  closing  his  mouth,  but  rather  to  finer  sounds  audible 
with  a  stethoscope  over  the  backs  alone  in  milder  cases  and  o\'er  the 
entire  chest  in  severer  ones. 

No  adequate  explanation  for  these  rales,  so  far  as  I  am  aware,  has 
ever  been  given,  but  the  rapidity  with  which  they  appear  and  disappear 
seems  to  })oint  to  some  vascular  condition  which  affects  the  lungs  directly, 
rather  than  through  any  change  in  the  heart's  action.  Certainly  they 
are  not  always  associated  with  cardiac  lesions,  but  may  be  associated 
with  the  most  forcible  and  efficient  action  of  that  organ. 

Outcome. — The  patient  was  lightly  etherized,  and  a  subpectoral 
infusion  of  four  pints  of  normal  saline  solution  was  given.  The  bowels 
were  moved  by  magnesium  sulf)hate,  and  a  hot-air  bath  was  administered. 


CONVULSIONS 


513 


He  had  to  be  partially  restrained,  owing  to  his  desire  to  get  up,  but  by 
February  2d  he  was  entirely  rational,  and  the  restraint  was  removed. 

X-ray  showed  cardiac  hypertrophy.  Hypertension  and  an  excess 
of  Hght-weight  urine  persisted. 

On  February  4th  he  was  allowed  to  go  home. 

Diagnosis. — Chronic  interstitial  nephritis;  vascular  crisis. 

Case  268 

A  shoemaker  of  twenty-seven  entered  the  hospital  June  28,  1908. 
He  had  been  in  the  hospital  in  the  previous  December  for  an  attack 
similar  to  the  present.  Four  weeks  ago  his  knee  became  swollen  and 
painful,  and  with  this  he  was  in  bed  for  two  weeks.  Since  then  he 
has  been  walking  with  crutches.  Yesterday  the  left  elbow  also  became 
swollen  and  painful.  This  afternoon  he  had  a  convulsion,  for  which 
he  was  brought  to  the  hospital.  He  had  similar  attacks  in  April  and 
in  February.  It  has  been  noticed  that  he  passed  an  increased  amount 
of  urine,  that  he  had  to  get  up  seven  or  eight  times  each  night  for  this 
purpose,  and  that  he  had  had  edema  of  the  legs  for  three  weeks  and 
almost  constant  headache.  He  has  vomited  four  or  five  times  a  week 
since  Januar)'.     He  has  no  dyspnea. 

At  entrance  the  patient  held  the  left  arm  across  his  body  in  a  condition 
of  moderate  spasm.  He  could  move  it  but  slightly.  The  left  elbow  was 
swollen  and  tender,  the  whole  arm  and  axilla  also  slightly  tender,  the 
dorsum  of  the  left  hand  swollen,  the  grip  very  weak.  There  was  no 
other  evidence  of  paralysis  or  weakness. 

The  heart's  apex  extended  \  inch  outside  the  nipple-line  in  the  fifth 
space,  the  right  border  i].  inches  to  the  right  of  midsternal  line.  A 
systolic  murmur  was  audible  at  the  base,  faint  at  the  apex.  There  was 
no  accentuation  of  cither  second  sound.  The  right  pulse  was  somewhat 
larger  than  the  left.     Blood-pressure  was  140  mm.  Hg. 

During  the  nine  days  of  the  patient's  stay  in  the  hospital  the  urine 
varied  from  ico6  to  1017  in  sy)eciric  gravity,  amounting  to  50  or  60 
ounces  in  twenty-four  hours.  All)umin,  from  0.7  per  cent,  to  2.4  j)cr 
cent.;  there  were  no  casts.  There  were  dc[)ressed  scars  on  the  right 
tibia  from  the  knee  to  the  ankle,  also  one  an  inch  above  the  inner  condyle 
of  the  left  tibia.     The  blood  was  negative. 

Discussion. — The  age  of  the  patient  and  the  condition  of  the  hctirt 
and  urine  a])parently  make  it  clear  that  we  arc  dealing  with,  a  rase 
of  chronic  glomerular  nephritis.  (Sec  Appendix  C.  on  The  ria>sihca- 
tion  of  the  Types  of  Nephritis.)     If  this  be  the  case,  the  arthritic  svmyv 

33  ' 


514 


DIFFERENTIAL  DIAGNOSIS 


toms  are  probably  due  to  a  low-grade  infection,  favored  by  the  weaken- 
ing of  resistance  which  chronic  nephritis  usually  entails. 

In  view  of  these  conclusions  it  would  seem  reasonable  to  interpret 
the  attack  as  uremic,  since  the  patient  has  had  previous  symptoms  indi- 
cating renal  insufficiency,  \iz.,  headache,  vomiting,  nocturia  and 
edema.  It  seems  altogether  probable  that  some  chemical  retention  will 
account  for  the  sudden  appearance  of  cerebral  symptoms  in  a  case  like 
this.     (For  fuller  discussion  of  this  matter  see  p.  509.) 

The  scars  u]:)on  the  shins  naturally  direct  our  search  toward  other 
evidences  of  syphilis,  but  as  none  such  are  forthcoming  the  possibiHty 
must  be  left  open. 

Outcome. — There  was  no  repetition  of  the  convulsions  while  in  the 
hospital— from  June  28th  to  July  7th. 

The  treatment  consisted  of  hot-air  baths,  purgation,  and  diet. 

Diagnosis. — Chronic  interstitial  nephritis;  uremia. 


Case  269 

A  child  of  fourteen  months,  who  had  never  been  sick  previously, 
entered  the  hospital  January  12,  1907.     She  fell  down  two  days  ago 

in  a  convulsion  and  has  since  then 
appeared  to  be  very  sick,  crying  much 
of  the  time,  and  extremely  thirsty. 
Yesterday  she  had  the  "shivers,"  but 
no  convulsion.  The  last  twenty-four 
hours  she  has  not  seemed  to  recognize 
her  mother,  and  has  vomited  occa- 
sionally. Whene^'er  she  is  touched 
anywhere,  she  cries  as  if  hurt.  There 
is  no  discharge  from  either  ear. 

On  examination,  numerous  white 
circular  scars  are  scattered  over  the 
body. 

There  is  convergent  strabismus, 
and  A'ision  is  apparently  impaired. 
Considerable  mucopurulent  secre- 
tion can  be  seen  in  the  pharynx. 
There  is  no  mastoid  tenderness,  no 
retraction  or  rigidity  of  the  neck: 
there  is  a  slight  fulness  under  the  angle  of  the  left  lower  jaw;  moderate 
rickety  rosary;  coarse  scjueaks  and  buljljling  sounds  are  heard  through- 


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CONVULSIONS 


515 


out  both  lungs.  Physical  examination,  including  the  reflexes,  is  other- 
wise negative. 

The  white  cells  are  18,300;  the  temperature  range  is  seen  in  the  ac- 
companying chart  (Fig.  128). 

Discussion. — It  used  to  be  the  fashion  to  attribute  most  of  children's 
convulsions  to  teething  or  colic,  and  it  is  still  generally  believed  that 
digestive  upsets  may  be  sufl&cient  to  produce  convulsions  which  in  older 
individuals  would  have  a  much  more  serious  significance.  In  the 
present  case  there  is  no  evidence  that  the  teeth  or  any  part  of  the  diges- 
tive tract  are  connected  with  the  seizure. 

Rickets  has  been  made  responsible  for  almost  e\ery  sym[)tom  and 
ill  to  which  a  baby's  flesh  is  heir.  On  p.  406  I  have  already  referred 
to  a  case  of  fatal  urinary  infection  in  which,  owing  to  the  presence  of  a 
rickety  rosary  and  some  slight  errors  in  diet,  the  clinical  diagnosis  was 
rickets.  I  have  known  similar  mistakes  made  in  various  other  cases 
in  which  a  slight  epiphyseal  enlargement  was  present.  The  moral  seems 
to  me  to  be  that  one  should  not  explain  any  severe  illness  as  due  to 
rickets  unless  there  is  other  evidence  of  that  disease  beside  a  rosary. 

The  child  is  thirsty,  suggesting  fever,  has  a  leukocytosis,  and  a  good 
many  rales  in  its  lungs.  Rales  may  sometimes  be  the  only  auscultatory 
evidence  of  broiichopncumonia.  Might  not  this  case  be  one  of  infectious 
bronchopneumonia  with  convulsions  at  the  onset?  I  have  ])rcviously 
noted,  howe\'cr,  that  rales  of  this  type  generally  distributed  throughout 
the  lungs  are  present  in  practically  all  cases  of  coma.  This  child  is 
apparently  semicomatose,  and  might  easily,  therefore,  have  many  rales 
of  this  type  without  the  existence  of  any  pneumonia.  jMoreo\cr,  the 
rales  of  l)roncho])neumonia  arc  only  distinctive  when  grou])ed  in  discrete 
patches  and  associated  with  a  good  deal  more  cyanosis  and  dys])nea 
than  are  present  in  this  case. 

In  an  adult,  meningitis  would  naturally  be  considered,  and  even  in 
a  baby  of  this  age  it  can  be  l)y  no  means  excluded.  Other  and  com- 
moner causes  for  conxuisions  should,  however,  l)c  first  in\cstigated. 

The  most  imj)ortant  of  these  causes  is  otitis  media.  1  ha\e  already 
referred  in  a  ])rcvious  case  to  the  fact  that  children  suffering  from  otitis 
do  not  usually  indicate  in  any  way  what  part  of  their  bod)-  is  affected. 
It  is,  therefore,  all  the  more  im|)ortant  tliat  we  should  write  u])()n  the 
tal)lets  of  our  memorv,  in  such  a  form  tliat  it  will  nc\cr  br  for- 
gotten wjicn  we  are  dealing  with  children,  the  motto:  "  J'^ciiuiiiht  r  the 
ears.'" 

Outcome.—  Txamination  of  the  ears  bv  a  specialist  >h(n\e(l  otitis 
media  on  the  left.     Paracentesis  allowed  the  escai)e  of  a  little  Moody 


5i6 


DirFERENTIAL  DIAGNOSIS 


and  purulent  fluid,  after  which  the  child  was  much  more  comfortable, 
though  there  was  still  some  deafness  in  the  left  ear. 

On  the  eighteenth  a  swelling,  apparently  a  gland,  appeared  at  the 
angle  of  the  left  jaw.  It  did  not  extend  up  in  front  of  the  ear  and  was 
not  tender.  Ten  days  later  it  was  still  persistent,  although  the  baby 
seemed  otherwise  entirely  well. 

Diagnosis. — Otitis  media. 

Case  270 

A  freight-handler  of   forty-seven  was  first   seen   on    June  2,  1905. 

He  has  had  a  markedly  alcoholic  history — five  or  six  whiskies  a  day. 

He  denies  venereal  disease.     He  has  been  well  up  to  six  months  ago, 

when  he  began  to  complain  of  short- 
ness of  breath  and  cough,  with  a 
"rush  of  blood"  to  the  head.  Two 
months  ago  his  eye-sight  began  to  fail, 
and  glasses  seemed  to  do  him  no  good. 
Within  the  past  year  he  has  had  to 
pass  water  twice  each  night. 

Ten  days  ago  he  felt  too  sick  to  go 
to  work,  vertigo,  dyspnea,  weakness, 
and  nausea  being  his  chief  symptoms. 
This  continued  until  three  days  ago, 
when  he  felt  better  and  went  out  for  a 
walk,  but  on  returning  he  had  a  con- 
vulsion lasting  three  minutes. 

For  the  past  week  he  has  been  for- 
getful and  incoherent  at  times.  At 
noon  to-day,  while  sitting  in  his  yard, 
he  went  into  a  convulsion,  with  coma 
and   snoring  breathing.     This  con\ail- 

sion  recurred  Ijefore  4  o'clock,  when  he  was   brought  to  the  hospital, 

still  unconscious. 

Physical  examination  showed  good  nutrition,  slight  enlargement  of 

the  glands  of  the  neck,  axillae,  and  groins,  nothing  abnormal  in  the  chest 

except  a  few  coarse  rales  at  the  base  of  the  lungs. 

The  abdomen  and  extremities  were  not  remarkable;  reflexes  normal. 

(See  Fig.  129.) 

The  white  cells  were  27,000;  urine,  20  ounces  in  twenty-four  hours; 

s[x;cific  gravity,  1022;    the  slightest  possible  trace  of  albumin;    a  few 


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Fig.  129. — Chart  of  case  270. 


CONVULSIONS  517 

hyaline  casts.  Examination  of  the  fundus  ocuH  showed  nothing  remark- 
able. 

The  patient  was  treated  with  milk  diet,  hot-air  baths,  and  magnesium 
sulphate. 

By  June  7th  he  was  fairly  clear  in  mind,  and  by  the  eleventh  seemed 
perfectly  well.  There  was  no  special  change  in  the  urine,  but  the  white 
cells  had  come  down  to  13,000. 

The  patient  was  seen  again  on  the  eighteenth  of  August,  1906.  He 
had  remained  in  good  health  and  had  no  trouble  with  his  eyes  until 
about  two  weeks  ago,  when  he  "began  to  feel  queer  "  and  had  frequent 
attacks  of  vomiting.  Three  days  ago  he  had  two  convulsions,  and 
has  had  several  of  the  same  since.  Bet\\'een  them  he  has  been  drowsy 
and  remembers  nothing.  His.  pupils  were  at  this  time  irregular,  the 
left  larger  than  the  right,  the  speech  thick.  He  was  unable  to  repeat 
his  alphabet  or  to  repeat  sentences  said  aloud  to  him.  His  blood- 
pressure  was  125  mm.  Hg. 

Physical  examination  otherwise  was  as  when  last  seen,  except  that 
the  white  cells  were  now  8000. 

Discussion. — In  all  cases  where  a  convulsion  is  the  presenting 
symptom  we  must  first  determine  the  question  of  epilepsy,  in  case  it 
seems  possible  to  exclude  all  gross  organic  changes  or  chemical  poisons 
as  causes  for  the  convulsion.  In  any  man  of  this  age,  however,  we 
should  always  be  very  skeptical  of  a  diagnosis  of  epilepsy.  Why  should 
it  begin  at  forty-seven,  when  it  is  well  known  that  the  vast  majority 
of  cases  of  epilepsy  begin  in  youth  or  young  adult  life.  Only  if  no 
other  possible  exj)lanation  can  be  found  is  such  a  diagnosis  justifiable 
in  a  patient  of  this  age. 

Although  the  patient  is  markedly  alcoholic,  there  seems  no  evidence 
of  any  unusual  indulgence,  such  as  might  determine  at  this  time  a  "rum 
fit." 

As  there  seems  to  be  no  residual  paralysis  or  focal  symptom,  we  have 
no  right  to  conclude  that  hemorrhage  or  tumor  is  present.  The  normal 
condition  of  the  fundlis  and  the  absence  of  any  long-standing  lieadache, 
vomiting,  or  vertigo  strengthen  the  evidence  against  cerebral  tumor. 

The  study  of  the  blood  and  urine  reveals  no  evidence  of  plumbism, 
diabetes,  or  nephritis.  The  latter  disease  is  still  further  debarred  from 
consideration  (in  its  chronic  form)  by  the  low  blo(xi-])ressure.  Acute 
inllammator}'  changes  (meningitis)  do  not  deserve  consideration,  e\en 
in  view  of  the  leukocytosis  present  at  the  time  he  was  first  seen,  for 
leukocytosis  occurs  in  all  acute  cerebral  seizures. 

Attacks  of  unex])laincd  convulsions  associated  with  marked  forget- 


5l8  DIFFERENTIAL   DIAGNOSIS 

fulness,  incoherence,  irregular  pupils,  and  some  disturbance  of  speech 
should  ahva}'s  lead  us  to  investigate,  by  further  tests,  the  possibility  of 
dementia  ])aralytica.  Such  tests  are,  especially,  the  condition  of  the 
hand-writing  as  compared  with  IJre^•ious  \cars,  the  presence  or  absence 
of  slight  changes  in  manner  or  habits,  the  cellular  constituents  of  the 
spinal  fluid,  and  the  Wassermann  reaction. 

Outcome. — August  24th  he  was  extremely  cordial  and  polite,  even 
efl"upi\e,  but  some  of  his  words  were  slurred,  as  if  he  were  drunk,  and 
his  talk  was  decidedly  muddled.  He  says  he  feels  excellently  well — 
better  than  for  ten  years. 

On  the  second  of  September  he  escaped  from  the  hospital  and  went  to 
early  mass,  clad  only  in   his  red  wrapper  and  carpet  slippers.      He 
returned  immediately  after  service  and  did  not  seem  to  realize  that  he 
had  done  anything  unusual.     The  later  course  of  the  case  confirmed  the 
diagnosis  of  dementia  paralytica. 

Diagnosis. — General  paralysis. 

Case  271 

A  manufacturer  of  sixty-two,  with  a  good  family  histor\',  entered 
the  hospital  January  2,  1908.  He  says  he  has  always  been  "tougher 
than  a  boiled  owl,"  though  he  had  diphtheria  when  a  child,  followed 
by  a  paralysis  of  both  legs.     His  habits  are  excellent. 

Three  weeks  ago  he  had  the  "grip,"  and  when  nearly  over  it  eight 
days  ago  caught  a  fresh  cold,  and  began  to  have  pain  in  both  wrists, 
knees  and  the  left  shoulder,  the  pain  not  severe,  but  catching  him  when 
he  moves.     He  has  had  no  other  symptoms. 

On  the  morning  of  entrance,  at  9.15,  he  had  a  series  of  short  general 
epileptiform  convulsions,  lasting  from  five  to  ten  seconds.  During 
these  the  pulse  fell  to  22  and  was  very  irregular.  There  were  periods 
of  fifteen  to  t\\'enty  seconds  when  no  pulse  could  be  felt  and  no  heart- 
beat heard;  following  this  came  an  epileptiform  convulsion  lasting  from 
three  to  live  seconds,  then  from  seven  to  ten  slow,  full  beats  of  the  heart; 
the  whole  cycle  would  then  be  repeated.  The  convulsions  were  accom- 
panied by  momentary  loss  of  consciousness,  with  flushing  of  the  face; 
there  was  no  cyanosis,  orthopnea,  drooling,  or  incontinence.  The 
breathing  throughout  was  deep  and  regular.  The  convulsions  lasted 
all  day  and  until  after  midnight,  when  they  became  less  frequent,  occur- 
ring at  I  A.  M.  and  5  A.  M. 

Physical  examination  sho-^ed  a  ])owcrful,  obese  man,  without 
glandular  enlargement,  with  pupils  altogctlicr  normal,  and  dry,  brown 
tongue.      The  heart-sounds  were  almost  inaudible.     The  heart's  impulse 


CONVULSIONS 


519 


was  neither  visible  nor  palpable;   by  percussion  there  was  no  evidence 
of  cardiac  enlargement.     The  belly  was  negative. 

The  blood-pressure  was  only  95  mm.  Hg.  and  the  arteries  were  barely 
palpable.  The  lungs  were  hyperresonant  ever}'where,  and  contained 
many  scattered  rales.  The  knee-jerks  were  not  obtained,  even  with 
reenforcement ;  the  Achilles  jerk  was  likewise  absent. 

The  joints  of  the  left  shoulder,  knee,  ankle,  and  the  right  wrist  were 
slightly  red,  swollen,  tender,  and  \er}-  painful  on  motion. 

The  course  of  the  temperature  is  seen  in  the  accompanying  chart 
(Fig.  130). 

The  white  cells  were  15,000  at  entrance;   18,500  two  days  later.    The 
joint  symptoms  rapidly  improved  under  sodium  salicylate,   10  grains 
every  hour,  and  a  dram  of  potassium 
citrate  e\ery  four  hours,  with  mild  laxa- 
tives. 

Discussion. — The  striking  point 
about  this  convulsion  is  its  associa- 
tion with  a  very  slow  pulse  and  periods 
of  pulselessness.  Almost  any  variety 
of  convulsion  may  be  associated  or  fol- 
lowed by  slow  pulse,  that  is,  by  a  re- 
duction in  the  number  of  beats  to  60 
or  e\'en  50  a  minute,  but  a  pulse  of  22, 
such  as  that  here  recorded,  has  a  \ery 
special  significance,  particularly  when 
the  general  condition  of  the  patient, 
both  before  and  after  the  convulsion, 
shows  no  evidence  of  heart  failure. 
Stokes-Adams'  disease  is  always  the 
first  working  hypothesis  to  be  con- 
sidered. 

Confirmation  of  this  diagnosis  can  be  obtained  only  by  the  study  of 
the  ^•enous  pulse  in  the  neck,  which  was  not  undertaken  in  this  case,  so 
that  no  certainty  can  be  arrived  at.  Xevertheless,  it  is  ahogelhcr 
])robable  that  if  such  a  study  had  been  undertaken,  evidence  that  the 
auricle  beat  more  frcfjuently  than  the  ventricle  would  have  been  found. 

Two  other  points  in  the  case  are  of  interest:  the  joint  symptom- 
and  the  absence  of  deep  retlcxes.  The  hitter  is  probably  to  be  explained 
as  a  resuh  of  the  dij)htheric  neuritis  of  his  childhood.  Tlie  normal 
condition  of  his  pu])ils.  tlie  good  control  of  tlie  sphincters,  tlie  absence 
of  characteristic  sensory  symptoms  are  sutTieient  to  exrhide  tabei. 


fharl  of 


520 


DIFFERENTIAL  DIAGNOSIS 


The  occurrence  of  multiple  arthritis,  accompanied  by  fever  and 
leukocytosis,  and  promptly  disappearing  during  che  administration  of 
salicylate,  is  cf  interest  to  me  because  I  have  several  times  observed  such 
an  attack  simultaneously  with  a  paroxysm  of  Stokes-Adams'  disease. 
The  fact  may  be  a  mere  coincidence,  though  one  may  also  conjecture 
that  the  blood  changes  accompanying  infection  may  interfere  with  the 
transmission  of  impulses  through  a  previously  diseased  bundle  of  His. 

Outcome. — The  patient  slept  a  great  deal  during  the  first  ten  days 
of  his  stay  in  the  hospital.  After  that  he  gradually  regained  his  appetite 
and  strength  until,  by  the  eighteenth,  he  seemed  altogether  normal  and 
was  allowed  to  go  home. 

Diagnosis. — Stokes-Adams'  disease  (?). 


Case  272 

A  cook,  sixty-eight  years  old,  was  first  seen   September  9,   1907. 

Six  brothers  and  three  sisters  died  of  unknown  causes.     Three  sisters 

and  two  brothers  are  well. 

For  eighteen  years  he  has  had  fits  without  known  cause.     In  them 

he  falls  suddenly  and  usually  without  warning.     Occasionally  he  bites 

his  tongue,  sometimes  he  "shakes." 

The  attacks  last  from  a  few  minutes 
to  an  hour,  and  are  usually  accom- 
panied by  coma.  They  may  come  from 
once  a  week  to  once  in  three  months; 
the  last  attack  was  two  months  ago. 
He  denies  venereal  disease.  He  drinks 
two  or  three  glasses  of  ale  a  day.  Eight 
weeks  ago  he  began  to  have  swelling  of 
his  legs  and  abdomen,  and  this  has 
steadily  increased  ever  since.  He  has 
passed  urine  once  or  twice  at  night  for 
twenty  years.  He  v.-orked  until  yester- 
day. 

The  patient  was  ill-nourished,  pale, 
with  normal  pupils  and  a  heart  extend- 
ing I  inch  outside  the  left  nipple  and 
Fig.  1,31.— Chart  of  case  272.  5t  inches  from  the  median  line;  sounds 

regular,  slow,  and  forcible.     A  moderate 

systolic  murmur  was  heard  all  over  the  precordia,  loudest  at  the  apex; 

blood-pressure  162  mm.  Hg.     The  arteries  were  palpable  and  tortuous 

above  the  elbow.     In  the  left  back  there  was  dulness  up  to  the  eighth 


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CONVULSIONS 


521 


rib  in  midaxilla,  and  to  the  seventh  rib  on  the  right.  Over  the  dull  area 
breath  sounds  and  crackling  rales  were  heard;  fremitus  was  feeble. 
There  was  dulness  in  the  flanks,  shifting  with  change  of  position,  marked 
soft  edema  of  the  legs  and  lower  eyelids.  By  tapping,  four  quarts  of 
straw-colored  serum  with  a  specific  gravity  of  1009  were  withdrawn 
from  the  abdomen.  In  the  sediment  of  this  fluid  lymphocytes  made  up 
82  per  cent. 

About  2  A.  M.  on  the  13th  of  September  the  patient  became  uncon- 
scious, and  had  general  epileptiform  convulsions,  lasting  about  ten 
minutes.  There  was  no  incontinence  or  biting  of  the  tongue.  Within 
the  next  two  days  he  had  six  more  such  attacks.  Each  began  with 
groaning  respiration,  which  in  a  short  time  altogether  ceased,  so  that 
the  patient  became  almost  black  in  the  face,  the  pulses  ceasing,  the 
heart-sounds  inaudible,  the  tongue  protruded.  Soon  he  breathed 
again;  the  heart-beat  rose  rapidly  to  80  in  a  minute,  then  again  fell  to 
about  25.  A  short  time  after  the  beginning  of  the  attack  the  muscles 
of  the  face  moved  con\'ulsively,  the  whole  body  became  rigid  and  then 
shook.  The  urine  and  feces  were  passed  involuntarily.  The  whole 
attack  lasted  from  half  a  minute  to  two  minutes,  and  was  followed  by 
unconsciousness  lasting  some  hours.  In  one  of  these  attacks  the  breath- 
ing ceased  for  over  two  minutes  by  actual  ol)servation.  The  heart  and 
pulse  began  again  before  the  respiration. 

Discussion. — This  patient  had  been  seen  by  several  j^hysicians  on 
account  of  the  convulsions  from  which  he  had  suffered  so  long,  and  it 
had  been  so  far  assumed  that  the  diagnosis  was  epilepsy.  I  have  already 
called  attention  to  the  rarity  of  epilepsy  beginning  after  the  attainment 
of  middle  age.  This  j)atient's  fits,  it  will  be  noticed,  began  when  lie 
was  fifty.     Presuma])ly,  therefore,  some  cause  for  them  can  be  found. 

The  evidences  of  arterial  degeneration  at  the  peri])heral,  the  moderate 
elevation  of  blood-pressure,  and  the  age  of  the  ])atient  make  it  {)ro|)er 
to  consider  cereljral  arteriosclerosis  or  general  arteriosclerosis  with 
vascular  crises  as  possible  cause  for  these  attacks.  Their  Icmg  duration, 
however,  is  against  this  sup])osition,  and  the  fact  that  there  is  stasis, 
e^■idenced  by  the  signs  in  the  lungs,  tlie  abdomen,  and  the  legs,  points 
also  against  vascular  crisis,  since  such  crises  usually  cease  wlicn  stasis 
begins. 

Dementia  paralytiai  rarely  ])r()duces  attacks  extending  through 
anything  like  so  long  a  ])crio(l  of  years.  It  is  true  that  the  disease  may 
nm  a  long  course,  but  a  duration  of  eighteen  years  after  the  ap])earance 
of  convulsions  and  without  any  more  marked  mental  or  motor  symptoms 
than  are  here  recorded  is  contrary  to  all  experience. 


522  DIFFERENTIAL   DIAGNOSIS 

The  most  important  fact  for  the  differential  diagnosis  is  the  cessa- 
tion of  the  pulse-beat  observed  during  the  attacks  which  occurred  in  the 
hospital.  This  is  \ery  suggestive  of  Stokes-Adams'  disease,  but  needs, 
of  course,  the  confirmation  obtainable  by  the  study  of  the  venous  pulse 
in  the  neck. 

Outcome. — Between  attacks  it  was  noticed  that  the  pulse  in  the 
veins  of  the  neck  was  to  the  radial  pulse  as  2  is  to  i,  or  as  3  is  to  2.  Syn- 
chronous tracings  confirmed  this. 

The  urine  averaged  20  ounces  in  twenty-four  hours,  specific  gravity 
1020,  the  slightest  possible  trace  of  albumin,  many  hyaline,  granular, 
and  epithelial  casts;  leukocytes,  8000.  By  fluoroscopic  examination 
the  auricular  beat  was  counted  at  62,  while  the  pulse  was  25.  The  fluid 
in  the  abdomen  rapidly  reaccumulated,  and  had  to  be  tapped  several 
times  before  the  patient's  death,  December  15.  Autopsy  showed  cir- 
rhosis of  the  liver  and  a  calcareous  ridge  in  the  region  of  the  bundle  of  His. 

Diagnosis. — Stokes- Adams'  disease.^ 

Case  273 

A  child  of  three  years,  of  good  family  history,  was  first  seen  May 
12,  1908.  She  has  always  been  subject  to  colds,  but  was  otherwise 
well  until  yesterda}'  afternoon,  when  she  had  a  convulsion,  more  or  less 
relieved  by  a  mustard  bath.  Later  she  vomited  twice  and  was  some- 
what feverish.  This  morning  she  began  to  cough  and  to  breathe 
rapidly.  The  course  of  the  temperature  is  seen  in  the  accompanying 
chart  (Fig.  133). 

The  tonsils  are  large  and  covered  with  a  whitish  exudate.  There 
are  small  tender  glands  on  each  side  of  the  neck.  The  neck  muscles 
are  not  at  all  rigid.  The  heart  shows  no  enlargement  in  any  direction. 
In  the  pulmonary  area  a  very  loud  systolic  murmur  is  heard,  completely 
replacing  the  first  sound,  and  transmitted  to  all  parts  of  the  chest. 
There  is  no  thrill.  The  pulmonic  second  sound  appears  to  be  much 
accentuated  and  reduplicated. 

Physical  examination  was  otherwise  negative;  the  white  cells,  10,700. 

Discussion. — Besides  the  convulsion,  the  essential  symptoms  seem 
to  be  cough  and  dyspnea,  associated  with  all  the  evidences  of  an  acute 
tonsillitis  and  a  cardiac  murmur. 

Before  concluding  that  the  convulsion  merely  expresses  a  reaction  on 
the  part  of  the  symptom  against  the  onset  of  the  infectious  tonsillitis, 

'  This  case  was  rc{)ortefl  by  Dr.  H.  F.  \'ickery  in  the  Boston  Medical  and  Surgical 
Journal,  Oct.  i,  1908,  and  is  reproduced  here  by  kind  permission  of  the  doctor  and 
the  journal. 


^^^f    L'<^. 


V'lii.  i,i-!.~  (  ah  ari'ous  ridia- iiU'jhin!^  tlic  lumdle  of  I  lis  in  a  casr  of  Siokc>-.\ilains' 
disease.  'Ilu-  arrow  jioip.is  to  the  rid;^e.  A  hit  has  iiet-n  till  out  for  mien  isco] 'ic  exami- 
nation. 1  rh'iti  seraph  I'v  Lewis  A.  lin'Wii.  Iscd  l>y  kind  ])ennissitin  of  ])r.  II.  1-'. 
\'ic  ker\- and  the  liiiSmn  Mediial  and  SiiiL^ital   loiirnal.! 


CONVULSIONS 


523 


we*  must  exclude  the  other  and  more  serious  possibilities.  Meningitis 
IS  one  of  these,  but  there  seems  to  be  nothing  definite  except  the  con- 
vulsion itself  to  support  this  idea.  Children  are  very  prone  to  show 
cervical  rigidity,  with  a  retraction  of  the  head,  strabismus,  and  Kcmig's 
sign,  even  when  meningitis  is  not  present;  but  the  absence  of  all  these 
symptoms  is  strongly  against  meningitis. 

Can  we  connect  the  cardiac  abnormalities,  hinted  at  by  the  murmur, 
with  the  convulsions?  Such  a  connection  might  be  made  out  in  case 
there  were  evidence  of  embolism  of  the  brain  or  lung,  of 
marked  cerebral  anemia,  or  of  a  broken  compensation 
involving  the  accumulation  of  COj  in  the  cerebral  cir- 
culation. But  we  have  no  reason  to  believe  that  any 
of  these  conditions  exist,  and  I  can  think  of  no  other 
way  to  connect  the  cerebral  and  cardiac  symptoms. 

The  ears  were  examined  without  showing  anything 
abnormal.  The  urine  showed  only  the  ordinary  results 
of  fever.  It  seemed  probable,  therefore,  that  our  original 
supposition  was  correct,  and  that  the  onset  of  the  ton- 
sillitis was  in  itself  sufficient  to  explain  the  convulsions. 

What  is  to  he  said  of  the  heart  murmur  ?  \'cry  loud 
murmurs  in  the  pulmonary  area  are  usually  the  result 
of  congenital  heart  disease.  This  is  probably  the  best 
diagnosis  to  make  in  the  present  case,  although  one 
would  feel  much  surer  of  it  if  any  cyanosis  and  thrill 
were  observable.  It  is  usually  unwise  to  attempt  any 
further  or  liner  description  of  the  anatomic  conditions 
in  congenital  heart  disease.  Autoj)sy  seldom  confirms 
the  details  of  our  diagnosis.  Those  who  have  seen  most 
cases  are  generallv  least  willing  to  commit  themselves  regarding  a  par- 
ticular lesion   or  coml^nation  of  lesions  which  is  ])roducing  the  trouble. 

Outcome. — There  was  no  repetition  of  the  conNiilsion,  and  within  a 
week  the  child  seemed  to  be  ])crfectly  well,  though  the  cardiac  murmur 
])ersisted  unchanged. 

Diagnosis. — Tonsillitis  and  congenital  heart  disease. 


^; 


Fig.     133. — Chart 
of  case  :!7^. 


Case  274 

.\  married  woman  of  thirty-four  with  three  healtli}'  children  \\a>  -cen 
September  8,  igog. 

She  has  liad  no  miscarriage.  Her  hus])and  denies  syphihV.  I^i\c 
years  ago  began  to  have  conxiilsions — typical  "epileps}-.'"  Con>i(leral)le 
headache  in  this  time,  and  occasional  diplopia. 


524 


DIFFERENTIAL   DIAGNOSIS 


Cureted  for  dysmenorrhea  five  years  ago  with  rehef  to  the  dysmenor- 
rhea, but  none  to  the  fits.  Had  tried  many  doctors  without  rehef.  For 
past  six  months  no  general  convulsions,  but  attacks  of  twitching  of  the 
right  hand  and  wrist,  apparently  provoked  by  excessive  use. 

Examination. — Choked   discs.     Urine   and   blood-pressure   normal. 

Lumbar  puncture  gives  clear,  non-cellular  fluid  under  pressure.     Viscera 

normal.     Later  she  developed  paralysis  of  external  rectus  and  ptosis  on 

the  left,  with  contracted  pupil.      Wassermann  test 

and  blood  negative. 

Died  September  9. 

Discussion. — This  patient  is  at  the  age  when 
ordinary  epilepsy  is  common.  The  most  notable 
feature  in  the  case,  however,  and  the  most  important 
from  the  diagnostic  point  of  view,  is  the  change  in 
the  nature  of  the  spasm  within  the  past  six  months. 
The  attacks  from  which  she  now  suffers  have  been 
diagnosed  as  "writer's  cramp,"  for  she  is  of  a  ver}' 
nervous  type,  and  has  done  a  great  deal  of  writing 
and  sewing  of  late. 

As  soon  as  we  had  observed  one  of  the  attacks, 
however,  it  became  obvious  that  it  had  nothing  to  do 
with  "writer's  cramp,"  that  it  was  wholly  involuntary, 
and  possessed  all  the  characteristics  of  Jacksonian 
epilepsy.  Localized  spasms  of  this  type  are  often 
seen  immediately  preceding  an  attack  of  ordinary  gen- 
eralized epilepsy;  in  fact,  pretty  much  all  epileptic 
attacks  begin  in  some  single  group  of  muscles.  It  is 
only  when  the  convulsion  fails  to  spread  beyond  the  original  group 
that  we  attribute  localizing  significance  to  it,  and  begin  seriously  to 
consider  a  circumscribed  lesion,  such  as  tumor,  cyst,  meningeal  adhe- 
sions, abscess,  or  softening. 

The  presence  of  choked  discs,  with  a  normal  urine  and  blood- 
pressure  and  normal  cerebral  spinal  fluid  obtained  by  lumbar  ])uncture, 
points  strongly  toward  brain  tumor.  Were  cerebrospinal  S}T3hilis,  tabes, 
or  i)aresis  present,  the  spinal  fluid  would  in  all  probability  show  an 
excess  of  cells.  The  negative  Wassermann  reaction  is  also  of  some 
significance,  although  in  this,  as  in  so  many  other  fields,  negative  evidence 
is  far  less  \aluable  than  positive. 

Meningitis  does  not  give  rise,  so  far  as  I  am  aware,  to  Jacksonian 
epilepsy,  and  the  content  of  the  spinal  fluid  suffices  to  exclude  it. 

There  seems  to  be  nothing  left  but  cerebral  tumor,  and  no  important 


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134. — Chart 
case  274. 


CONVULSIONS  525 

evidence  against  it.  At  first  sight  the  long  duration  of  her  illness — 
the  five  years  of  typical  "epilepsy" — seems  confusing,  but  there  are 
now  on  record  a  considerable  number  of  cases  in  which  cerebral  tumor 
has  been  demonstrated  at  autopsy  after  a  number  of  years  of  headache 
and  convulsive  attacks,  like  those  here  described. 
Diagnosis. — Cerebral  tumor. 

Case  275 

A  physician  of  fifty  was  seen  Octol^er  28,  1908.  He  has  always  been 
well  until  eight  years  ago,  when  he  had  a  good  deal  of  pain  in  his  lumbar 
region  and  down  the  back  of  his  right  leg.  For  this  he  consulted  Dr. 
J.  E.  Goldthwait,  who  put  him  into  a  plaster  jacket,  with  marked 
relief. 

After  this  he  was  well  until  three  years  ago,  when  he  had  "some 
kind  of  a  spasm,"  the  nature  of  which  cannot  be  more  accurately  learned. 
In  July,  1907,  he  was  seized  with  some  sort  of  an  attack  during  the  night 
while  in  his  bath-room.  He  found  himself  on  the  floor,  and  was  unable 
to  get  to  his  feet,  but  crawled  back  to  bed.  Ever  since  that  time  it 
has  been  noticed  that  his  gait  is  somewhat  shuffling  or  shambling, 
especially  when  he  is  much  fatigued. 

In  September,  1907,  he  had  an  attack  of  catarrhal  jaundice.  A  con- 
sultant saw  him  at  that  time  and  considered  it  a  case  of  "brain-fag." 
Muscular  power,  sensation,  and  the  pupils  were  then  examined  and 
found  to  be  normal.  During  the  next  six  months,  however,  he  had  a 
number  of  attacks  of  vomiting  without  ob\ious  cause  and  without 
relation  to  meals.  They  did  not,  however,  pre\ent  his  carrying  on  a 
very  active  practice,  in  which  he  has  been  engaged  up  to  the  present 
time. 

In  September,  1908,  he  had  a  !)ad  nose-bleed,  and  next  day  seemed 
very  weak,  with  profuse  sweating  and  marked  j^allor.  To  these  nose- 
bleeds he  says  he  has  been  subject  all  his  life.  Many  other  members 
of  his  family  have  a  similar  tendency. 

October  27,  1908,  the  day  l^efore  the  one  on  which  I  saw  him,  he 
was  seized  about  6  p.  m.  with  a  general  epileptiform  convulsion,  and 
within  the  next  twenty-four  hours  he  had  nine  similar  attacks.  The 
first  convulsion  followed  immediatelv  u])on  the  eating  (^f  a  \ery  hea\y 
meal.  After  it  he  was  comatose,  and  between  the  su])sequent  conxul- 
sions  he  did  not  fullv  regain  consciousness  until  about  three  hours  before 
the  time  at  which  T  saw  him. 

On  examination  he  was  normallv  conscious,  intelligent,  and  cheerful. 
There  was  no  paralysis  anywhere,  and  the  tendon  retlexes  were  normal. 


526  DIFFERENTIAL  DIAGNOSIS 

The  pupils  immobile.  The  heart,  lungs,  and  abdominal  viscera  showed 
nothing  worthy  of  note  except  that  the  aortic  second  sound  was  sharp 
and  ringing,  and  the  pulse  of  high  tension.  As  he  spoke  to  me  in  answer 
to  questions  I  noticed  an  occasional  stumbling,  and  now  and  then  the 
elision  of  a  syllable.  He  said  he  felt  quite  w^ell,  and  wanted  to  make 
some  medical  calls  that  afternoon. 

On  subsequent  inquiry  it  was  learned  that  his  urine  had  been  ex- 
amined several  times  in  the  past  eighteen  months  and  always  found 
to  contain  a  trace  of  albumin.  He  had  sometimes  had  a  little  trouble 
in  urination,  and  once  last  summer  involuntary  defecation  took  place. 

Discussion. — Every'  physician  sees  many  cases  of  this  type,  if  one 
omits  the  history  of  the  convulsion.  In  the  absence  of  such  convul- 
sions as  were  here  described  the  diagnosis  of  neurasthenia  is  very  fre- 
quently made.  Such  a  diagnosis,  in  my  opinion,  is  never  justified 
when  the  patient's  symptoms  first  appear  at  or  after  middle  life.  Nervous 
weakness  under  these  conditions  means  organic  disease  with  nervous 
manifestations.  The  underlying  trouble  is  most  often  cardiovascular 
disease,  with  or  without  a  demonstrable  arteriosclerosis.  The  per- 
i  sistent  elevation  of  the  blood-pressure,  which  is  almost  always  to  be 
'  found,  should  put  us  on  our  guard  against  the  mistake  of  supposing  the 
patient  to  be  "merely  nervous." 

In  all  such  cases,  however, — and  more  especially  when  a  con^'ulsion 
has  occurred, — we  should  make  such  inquiries  as  would  serve  to  de- 
termine whether  any  evidence  of  beginning  dementia  paralytica  is 
present.  In  a  jjhysician  carrying  on  an  active  and  successful  practice 
it  may  seem  hardly  justifiable  to  consider  so  serious  a  disease,  but  in 
the  present  patient  inquiry  brought  out  the  following  points: 

{a)  His  hand-writing,  always  indistinct,  had  now  become  so  illegible 
that  apothecaries  were  frequently  unable  to  decipher  his  prescriptions. 
(I  fear  this  happens  to  many  not  demonstrably  the  victims  of  dementia 
paralytica.) 

(h)  His  wife  had  noticed  that  he  had  recently  become  entirely  in- 
capable of  making  up  his  accounts  or  doing  even  simple  sums  in 
arithmetic. 

(c)  Despite  the  vagueness  and  inaccuracy  of  his  account  books,  he 
was  very  cheerful,  if  not  optimistic,  u})on  money  matters,  though  his 
wife  declared  with  tears  that  he  had  little  ground  for  such  optimism. 

(d)  He  has  fallen  into  the  habit  of  dropi)ing  asleep  while  at  work, 
or  even  in  the  midst  of  a  conversation,  and  his  attention  at  all  times  is 
-hort-lived  and  wandering.  (This  is  true,  also,  of  many  other  members 
of  his  family,  and,  indeed,  of  the  human  family.) 


CONVULSIONS  527 

{e)  His  memory  and  decisiveness  of  action  have  been  gradually 
failing  for  many  months. 

[f)  It  has  been  noticed  that  he  drops  things  very  frequently,  and 
complains  that  he  has  no  feeling  in  his  fingers. 

In  view  of  these  mental  and  psychomotor  changes  the  diagnosis  of 
dementia  paralytica  seemed  to  me  clear. 

Outcome. — The  patient  went  away  for  a  few  weeks  on  a  vacation 
soon  after  I  saw  him.  He  then  returned  to  Boston  and  tried  to  resume 
practice,  aided  by  a  very  old  friend,  a  physician,  who,  for  friendship's 
sake,  was  willing  to  go  everywhere  with  him  and  make  good  his  mis- 
takes. 

On  February  13,  1909,  he  had  another  convulsion,  and  March  loth 
a  general  tonic  clonic  spasm,  without  loss  of  consciousness.  After  this 
he  gradually  improved  in  strength,  gait,  and  ability  to  write,  but  his 
personal  habits — previously  most  correct — became  somewhat  untidy. 
May  25th  he  went  to  his  old  home  on  a  Maine  farm,  where  he  passed 
the  summer  in  reasonable  comfort.  October  3,  1909,  he  seemed  in 
unusually  good  spirits,  but  at  midnight  he  had  a  series  of  convulsions 
and  died  within  a  few  hours. 

Diagnosis. — Dementia  paralytica. 

Case  276 

July  9,  1906,  I  was  called  to  a  small  town  in  the  southern  part  of 
Massachusetts,  on  the  outskirts  of  which  lived  a  farmer  whose  wife  I 
was  asked  to  sec  for  the  relief  of  convulsions  of  unknown  origin.  She 
was  a  woman  of  twenty-eight,  of  excellent  family  history,  and  had 
always  up  to  this  time  been  well  and  strong.  Nine  weeks  previously 
she  had  borne  her  first  child,  parturition  and  the  convalescence  from  it 
being  nonnal. 

Three  weeks  before  I  saw  her  she  consulted  her  physician  on  account 
of  persistent  headache,  an  entirely  new  sym])tom  for  her.  A  week 
later  she  was  noticed  to  ])e  distinctly  pale.  Iron  was  jjrcscril)cd,  and  she 
seemed  to  ])e  doing  well  until  eight  days  ago.  when  she  had  an  attack 
of  vomiting  without  any  known  reason.  Such  attacks  ha\e  recurred 
every  day  or  two  since  that  time. 

Five  days  ago  she  had  her  first  c])ileptiform  convulsion,  wliich  was 
followed  within  twelve  hours  by  a  second  couAuIsion  in\'oh'ing  only 
the  muscles  of  the  right  half  of  the  bodv.  Yowv  davs  ago  a  similar 
unilateral  conMilsion  occurred.  Yesterdav  she  had  a  gemrali/cd 
con\"ulsi()n  \\ithout  loss  of  consciousness.  Tlie  urine  lias  liceii  sc\eral 
times  examined.     It  is  alwavs  rather  scantv,  but  has  ncwr  sli()\\n  anv 


528  DIFFERENTIAL  DIAGNOSIS 

albumin.  The  gravity  has  averaged  1024,  the  color  rather  darker  than 
normal.     She  has  voided  27  ounces  in  the  past  twenty-four  hours. 

Between  the  convulsive  attacks  she  seems  pretty  well,  though 
rather  weak.     There  has  been  no  pain  at  any  time  and  no  paralysis. 

Physical  examination  of  the  chest  and  abdomen  was  entirely  nega- 
tive. The  reflexes  and  pupils  were  normal;  the  hemoglobin,  50  per 
cent;   the  urine  free  from  albumin,  and  otherwise  as  above  described. 

Discussion. — Naturally,  our  first  attempt  in  such  a  case  is  to  relate 
the  convulsions  in  some  way  to  the  recent  childbirth,  but  this  seems, 
on  reflection,  rather  far  fetched,  as  the  woman  was  in  perfect  health 
for  the  six  weeks  following  parturition. 

Uremia  seems  to  be  excluded  by  the  absence  of  any  cardiac  hyper- 
trophy or  urinary  changes.  Unfortunately,  the  blood-pressure  was 
not  measured.  To  the  palpating  finger  the  arterial  tension  seemed 
unusually  low. 

Without  an  examination  of  the  fundus  oculi  one  cannot  speak  with 
confidence  against  the  possibility  of  brain  tumor;  but  there  is  really 
little  to  suggest  it,  local  symptoms  being  entirely  absent,  the  headache 
being  very  moderate  and  unaccompanied  by  vertigo. 

In  the  physical  examination  and  in  the  reasoning  process  above 
reproduced  one  essential  step  has  been  omitted  primarily,  because 
in  the  first  fifteen  minutes  of  my  study  of  this  case  it  was  altogether 
forgotten,  also  because  it  never  occurred  to  the  mind  of  the  attending 
physician.  Both  of  us  forgot  to  consider  lead-poisoning.  After  my 
first  unsatisfactory  and  fruitless  review  of  the  case  I  began  again  and 
went  over  the  patient  systematically  from  head  to  foot.  On  the  gums 
I  found  this  time  a  typical  lead-line,  which  I  had  previously  omitted  to 
look  for,  because  lead-poisoning  is  associated  in  my  mind  chiefly  with 
those  who  work  in  some  trade  involving  the  use  of  lead.  A  young 
woman  living  in  the  depths  of  the  country  and  doing  no  work  outside 
her  own  house  does  not  necessarily  suggest  the  possibility  of  lead- 
poisoning. 

After  finding  the  evidence  of  lead  in  her  gums  I  began  to  wonder 
where  she  could  have  acquired  the  metal.  Could  it  be  from  drinking 
water?  If  so,  other  members  of  the  family  should  be  affected.  I 
turned  at  once  to  the  husband,  standing  at  the  foot  of  his  wife's  bed, 
and  examined  his  gums.  They  also  showed  a  typical  lead-line,  though 
he  had  had  no  symjAoms.  There  was  no  one  else  in  the  house  but  the 
baby,  who  had  taken  no  water  and  seemed  to  be  quite  healthy. 

The  family  then  recollected  that  the  water  had  tasted  queer  since 
the  previous  winter,  but  they  had  been  using  the  same   well-water  for 


CONVULSIONS  529 

the  past  three  years.  About  100  feet  of  lead-pipe  intervened  between 
the  well  and  the  house. 

The  patient  was  ordered  to  drink  no  more  of  this  water,  to  take 
5  grains  of  potassium  iodid  three  times  a  day,  and  a  purge  of  magnesium 
sulphate  every  morning.  The  con\'ulsions  ceased  at  once,  and  the 
patient  made  a  rapid  and  lasting  recover}'. 

Diagnosis. — Lead-poisoning. 

Case  277 

In  July,  1893,  a  gentleman  of  forty-nine  entered  the  hospital  with 
the  diagnosis  of  astasia  abasia,  made  by  a  neurologist  three  weeks 
previously.  He  remained  in  the  hospital  for  three  months,  during 
most  of  which  time  he  had  partial  paralysis  of  the  leg,  relaxed  sphincters, 
and  a  great  number  of  complaints  referred  to  difTerent  parts  of  his 
body.  The  reflexes  were  never  markedly  abnormal,  and  visceral 
examination  was  always  negati\e.  He  gradually  improved  until  he 
was  able  to  walk  with  a  cane,  left  the  hospital,  and  was  not  seen  again 
until  1903. 

During  most  of  the  intervening  decade  he  lived  in  India  or  in  Egypt, 
painted  a  good  many  pictures,  and  enjoyed  himself  thoroughly.  In 
1900  he  had  an  indolent  abscess  on  his  forehead,  which  did  not  heal 
after  it  had  been  opened,  and  showed  no  considerable  improvement 
for  six  weeks.  After  that  he  was  given  some  medicine  "with  a  salty 
taste,"  and  the  abscess  promptly  healed. 

Since  1897  he  has  been  troubled  with  attacks  diagnosed  as  "petit 
mal."  These  occur  every  t\\  o  to  five  days,  and  last  about  half  a  minute. 
A  typical  attack  begins  with  slight  nausea  and  a  bad  taste  in  the  mouth ; 
next  he  begins  to  notice  a  sudden  change  in  the  behavior  of  the  ])eo])le 
around  him.  They  seem  to  be  walking  so  as  not  to  disturb  him,  or 
creeping  toward  him.  After  this,  comes  a  tremor  or  thrill  down  the 
left  arm  and  an  in\oluntary  closing  of  the  left  thumb  and  index-finger, 
with  some  shaking  of  the  whole  hand,  so  that  he  may  almost  dro{) 
his  ne\vsj)aj)er  if  he  is  reading  one  at  tlie  time.  All  the  colors  of  the 
objects  around  him  become  intensified.  He  does  not  think  that  any 
one  about  him  notices  what  is  going  on.  Between  these  attacks  he 
feels  pretty  well,  but  occasionally  wets  liis  bed  at  night,  and  ah.^ays 
])asses  water  five  or  six  times  after  he  gets  to  l)ed.  Occasional!}-  he  has 
noticed  that  his  linen  is  stained,  owing  to  relaxation  of  the  rectal  >j'hinc- 
ter. 

In  igo4  he  went  abroad  and  enjoyed  himself  \er\-  much.      X'arious 

English  doctors  told  him  that  hi>  troubles  were  all  due  to  goui.     ( )cca- 
34 


53©  DIFFERENTIAL  DIAGNOSIS 

sionally  his  left  ankle  gives  way  under  him,  but,  as  a  rule,  he  walks 
very  well.  November  7,  1904,  he  fell  unconscious  in  a  water-closet, 
and  for  half  an  hour  afterward  was  drowsy  and  drooled  saliva.  January 
21,  1905,  after  four  days  of  excellent  spirits  and  entire  absence  of  the 
attacks  of  "petit  mal,"  he  woke  up  in  the  night  with  severe  pain  across 
his  forehead,  a  very  sore  tongue,  and  much  sensitiveness  of  his  muscles, 
especially  across  the  loins.  For  the  whole  day  following  this  he  was 
very  sleepy  and  stupid. 

February'  20th  he  started  to  dine  with  a  friend  in  Cambridge.  The 
next  thing  that  he  knew  he  found  that  the  electric  car  in  which  he  was 
had  come  to  the  end  of  its  route,  in  surroundings  which  he  did  not  at 
all  recognize.  How  he  got  there  he  had  no  idea.  About  three-quarters 
of  an  hour  had  elapsed  since  he  took  the  car  for  Cambridge.  Next  day 
he  noticed  that  his  left  foot  dragged  a  little  in  walking. 

In  1906  he  began  to  have  trouble  with  his  rectum,  and  a  tiimor  was 
felt  high  up  upon  the  right.  Operation  showed  an  apparently  inopera- 
ble tumor  mass  involving  a  large  portion  of  the  rectum  and  lower  sigmoid. 
An  artificial  anus  was  made,  after  which  he  was  greatly  better.  Four 
years  later  there  had  been  no  increase  of  s^nnptoms.  The  artificial 
anus  was  working  excellently  well.  Occasional  attacks  of  uncon- 
sciousness, with  or  without  generalized  convulsions,  and  ver\'  many  of 
the  seizures  called  "petit  mal,"  still  troubled  him. 

Discussion. — Twice  this  patient  was  given  up  to  die — the  first  time 
in  1893,  the  second  time  in  1897;  yet  he  is  alive  and  healthy  (1910).  The 
most  important  diagnostic  and  therapeutic  indication  in  his  case  was 
to  my  mind  the  so-called  abscess  on  the  forehead,  which  resisted  all 
ordinary  treatment  and  then  healed  so  promptly  after  the  administra- 
tion of  a  medicine  which  had  the  taste  of  potassium  iodid.  The  patient 
had  no  knowledge  of  any  syphilitic  infection,  but  had  lived  the  type  of 
life  in  which  such  infections  are  acquired.  I  see  no  reason  to  doubt 
that  all  his  symptoms  were  due  to  syphilis  in  one  form  or  another. 
First  the  spinal  cord,  later  the  brain,  and  finally  the  perirectal  tissues 
were  involved. 

The  question  of  operation  for  the  relief  of  his  attacks  of  "petit  mal" 
was  often  and  seriously  considered,  but  in  \iew  of  his  pre\ious  history 
it  seemed  probable  that  the  disease  was  so  widely  difi"used  that  little 
could  be  expected  from  0])erative  interference. 

Diagnosis. — Syphilis. 


CONVULSIONS 


531 


Meningitis 

< 

3. 

u 

I 

3 

Epilepsy 

> 

n 
0 
3- 

3 

Infantile  spasm 

Eclampsia  (puerperal) 

Causes. 

Previous 

evidence   of 

nephritis. 

Habits. 

Temperament. 

Previous 

attacks. 

Sudi'en  onset. 

No  previous 

attack. 

Previous 
attacks. 

Childbirth, 
recent  or 
imminent. 

Previous  at- 
tacks.    Diges- 
tive upsets. 

Habits. 

Aids  from 
history. 

+ 

D 

3 

5" 

0 

0 

Often. 

Often. 

Fever. 

r? 

^  X" 


^  <^ 


—    5   3 


£'3- 


CHAPTER  XVII 

WEAKNESS 

So  many  patients  consult  a  physician  complaining  primarily  of 
weakness  that  I  have  thought  it  best  to  discuss  it  and  to  illustrate  it  by 
cases,  although  so  little  is  known  regarding  the  manner  of  its  production 
in  the  great  majority  of  })atients.  We  must  make  at  the  outset  a  dis- 
tinction which  is  often  not  noticed  by  patients  themselves,  the  distinction, 
namely,  between: 

(a)  Paralysis  due  to  organic  lesions  of  the  brain,  cord,  or  peripheral 
nerve. 

(b)  Hysteric  and  psychasthenic  " f orgetf ulness "  (Janet),  whereby 
a  patient  loses  control  of  his  motor  tract. 

(c)  Weakness  in  the  narrower  sense,  excluding  (a)  and  (b),  and  due 
to  a  great  variety  of  defects  in  nutrition,  excretion,  or  blood-supply. 

Of  this  latter  type  of  functional  insufficiency  we  really  have  very 
little  knowledge.  It  is  often  said  that  anemia  is  directly  and  in  itself 
the  cause  of  many  weakened  states,  yet  I  had  under  my  care  for  three 
years  a  patient  with  pernicious  anemia  who  was  in  the  habit  of  taking 
a  daily  swim  of  about  a  mile  in  the  Charles  River,  when  his  red  cells 
numbered  less  than  1,500,000  per  c.mm.  He  also  walked  to  and  from 
his  w^ork, — a  distance  of  about  two  miles  each  way, — and  was  very 
actively  engaged  as  a  salesman  in  the  basement  of  a  department  store 
for  nearly  twelve  hours  in  every  twenty-four.  In  view  of  this  and 
similar  cases  it  is  difficult  to  believe  that  anemia  is  in  itself  the  all- 
important  cause  of  weakness  such  as  we  should  often  be  led  to  suppose. 

It  is  also  well  known  that  the  size  of  muscles  and  their  firmness  have 
only  a  rough  and  general  relation  to  their  strength.  Some  of  the  most 
remarkable  athletes  have  small  and  apparently  soft  muscles. 

In  a  large  group  of  cases  weakness  appears  as  the  result  of  cardiac 
insufficiency,  l)ut  even  here  it  is  difficult  to  fix  the  blame,  since  dyspnea 
is  so  intimately  related  to  the  disabilities  of  which  the  patient  com- 
plains. 

Fever  is  likewise  associated  in  our  minds,  and  apparently,  in  fact, 
with  many  cases  of  weakness,  yet,  on  the  other  hand,  we  have  all  of 
us  dealt  w^ith  })atients  who  feel  much  brighter  and  better  when  their 
temperature  is  elevated  than  when  it  is  normal. 

532 


Causes  of  Paralysis 


'APOPLEXY'        

w  IT  H  H  E  M  I- }-  j^K^Kmt^^^mm^^^K^mmm^^mi^^ai^m  346 


PLEGIA 
TABES  DORSALIS      ■■^^■^^^i^^^ii^^^^^^HHHHHi 


POLIOMYELITIS         HHi^^l^^^^HHHil^^^HI  227 


DEMENTIA 
PARALYTICA 


PARKINSON'S 
DISEASE 


ATAXIC  ■» 

paraplegia/ 


121 


NEURITIS  HIH^iHH  80 


44 


BIRTH   PALSY  ■■■  40 


35 


LATERAL         )  ^^ 

sclerosis/  ^^  ^^ 


r:;:? 


WEAKNESS  535 

Despite  all  these  limitations  of  our  knowledge  it  is  doubtless  true 
that  anemia,  lack  of  muscular  development,  cardiac  insufficiency, 
malnutrition,  and  fever  are  in  some  way  connected  with  the  weakness 
of  which  our  patients  complain.  Clinically,  such  complaints  are  most 
often  associated  with  the  following  conditions: 

1.  Neurasthenia  and  other  psychoneuroses. 

2.  Tuberculosis. 

3.  Anemia. 

4.  Bad  hygiene. 

5.  Nephritis. 

6.  Valvular  heart  disease. 

7.  Convalescence  from  acute  respirator}'  infections  ("influenza"). 

8.  Diabetes. 

9.  Hyperthyroidism. 

In  the  latter  two  diseases  we  have  the  striking  phenomenon  of  loss 
of  weight  and  strength  despite  good  appetite.  Besides  those  alx)ve 
listed,  one  sees  now  and  then  a  patient  complaining  only  of  weakness, 
yet  proving,  on  examination,  to  have  typhoid  fever.  The  same  is  true 
of  myxedema  and  not  infrequently  of  obesity. 

Case  278 

An  expressman,  thirty  years  old,  of  good  family  history  and  good 
habits,  had  pneumonia  seventeen  years  ago,  and  again  seven  years 
ago.  Six  years  ago  he  passed  a  life-insurance  examination  and  was 
told  that  his  lungs  were  sound.     He  was  first  seen  October  29,  1906. 

He  has  been  feeling  entirely  well  until  about  two  years  ago,  when 
he  began  to  get  weak,  lost  his  apj)ctite,  and  felt  some  nausea  and  faint- 
ness.  He  kept  at  work,  however,  until  October,  1905,  when  he  went 
to  his  father's  home  in  New  York  State,  was  out-of-doors  hunting, 
and  felt  much  stronger  and  ])etter,  but  still  was  not  cured. 

Some  time  after  this  he  had  jaundice.  He  was  treated  with  calomel, 
but  did  not  im])rove.  He  went  ])ack  to  work  in  Fel)ruary,  1906,  but 
in  May  l^roke  down  again,  and  since  then  has  ne\"er  been  able  to  work 
more  than  three  weeks  at  a  time  on  account  of  weakness. 

At  no  time  has  he  had  any  pain,  but  his  weakness  gradually  became 
so  troublesome  that  six  weeks  ago  he  ga\e  up  work  for  good. 

His  a])petite  has  been  poor  throughout  this  illness,  but  for  tlie  past 
three  weeks  he  has  eaten  almost  nothing  because  he  cannot  bear  the 
sight  of  food.  He  has  had  no  vomiting,  no  ])ain  anywhere,  and  his 
bowels  hu\e  mo\cd  regularly  once  a  day. 

For  the  i)ast  two  weeks  he  has  been  \"ery  sleepy,  and  found  itdifhcult 


536 


DIFFERENTIAL  DIAGNOSIS 


to  keep  awake  in  the  day-time.  For  the  past  two  weeks  he  has  taken 
beef-juice  in  teaspoonful  doses,  but  no  other  food.  He  has  had  no 
drugs  except  sodium  phosphate.  Of  this,  he  says  he  has  used  half  a 
bushel-basket  full  of  bottles. 

A  year  ago  he  weighed  125  pounds,  now  he  weighs  103. 
On  examination  the  patient  is  emaciated.     His  breath  shows  an 
odor  like  acetone.     His  skin  is  of  a  dark  yellow  hue. 

His  heart  is  negative,  except  that  the  sounds  are  very  faint.  His 
pulse  is  of  very  low  tension;   his  blood-pressure,  50  mm.  Hg. 

The  edge  of  the  liver  is  just  palpable  below  the  ribs  on  full  inspira- 
tion.    The  knee-jerks  are  absent. 

There  is  no  edema.     The  urine  is  negative. 

The  temperature  is  as  seen  in  the  accompany- 
ing chart. 

Red  cells  are  5,040,000;  white  cells,  17,200; 
hemoglobin,  85  per  cent.;  69.5  per  cent,  of  the 
leukocytes  polynuclear,  the  remainder  lympho- 
cytes, the  majority  of  which  are  very  large.  The 
blood  is  otherwise  normal,  repeated  search  for 
malarial  parasites  being  fruitless. 

The  stools  showed  nothing  abnormal  except 
a  slight  reaction  with  the  guaiac  test.  The  vomitus 
showed  no  hydrochloric  acid;  nothing  else  of 
interest. 

Extreme  weakness  was  practically  his  only 
symptom. 

Discussion. — The  marked  gastric  symptoms 
complained  of  by  this  patient  direct  our  search 
first  toward  some  cause  in  the  gastro-intestinal 
tract. 

(a)  Anorexia  nervosa  often  produces  a  condi- 
tion even  more  serious  than  the  one  now  under 
discussion.     Indeed,  it  is  not  infrcfjuently  fatal.     But  in  a  person  of 
this  age,  sex,  and  manner  of  life  it  is.  so  far  as  I  know,  unknown. 

(b)  Cancer  of  the  stomach  may  occur  at  this  age  or  even  earlier, 
though  such  an  occurrence  is  \'ery  rare.  One  of  its  earliest  symptoms 
is  often  a  complete  loss  of  apjjetite,  such  as  this  patient  suffered.  The 
absence  of  hydrochloric  acid  in  the  vomitus  would  seem  to  support  this 
hy{)othesis.  On  the  other  hand,  in  a  patient  so  markedly  emaciated 
we  should  certainly  ex{)ect  to  feel  a  tumor,  especially  as  the  symptoms 
seem   to   have   lasted   two   years.     Other  gastric   symptoms — such   as 


(JJt^ 

- 

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•KU- 

i^l 

A 

ii 

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3 

v 

; 

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II- 

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A 

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a 

H 

a 
u 
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w 
w 

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110 

lU 
IM 

no 

It 

M 
U 

w 

M 
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m 
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f 

P 

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tf 

i 

d 

i 

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_. 

Fig.  135. — Chart   of 
case  278. 


WEAKNESS 


537 


stasis  and  vomiting — would  certainly  have  appeared  by  this  time  in 
the  great  majority  of  cases  of  gastric  cancer. 

(c)  The  enormous  amount  of  sodium  phosphate  which  this  patient 
had  taken  might  cause  us  to  conjecture  that  he  has  poisoned  himself 
with  the  drug  were  there  any  evidence  that  it  is  capable  of  producing 
toxic  symptoms;  but  so  far  as  I  know  there  is  no  such  evidence. 

The  patient's  yellow  pallor  reminded  me  strongly  of  some  of  the 
cases  of  chronic  malarial  poisoning  which  I  had  seen  in  soldiers  return- 
ing from  the  Cuban  war,  but  the  results  of  blood  examination  absolutely 
excluded  malaria. 

As  there  was  no  discoloration  of  the  conjunctivas  and  no  bile  in  the 
urine,  we  did  not  consider  a  chronic  hemolytic  jaundice.  The  low 
blood-pressure  and  the  great  emaciation  were  such  as  one  often  sees 
in  the  latest  stages  of  some  form  of  tuberculosis.  There  were  no  lesions, 
however,  discoverable  by  physical  examination,  and  no  fever. 

The  absence  of  knee-jerks  was  not  explainable  by  any  of  the  diag- 
noses which  we  considered.  There  was  no  sufficient  reason  to  con- 
sider tabes,  as  there  were  no  sensory,  pupillar\',  or  sphincteric  changes 
and  no  pain.  Ver}'  possibly  he  may  have  passed  through  an  attack 
of  peripheral  neuritis  at  some  previous  time,  but  there  was  no  reason 
to  connect  it  with  the  present  symptoms. 

Addison's  disease  produces  the  lowest  blood-pressure  that  has  been 
observed,  so  far  as  I  know,  in  any  disease  previous  to  the  moribund  state. 
It  is  often  associated  with  gastric  symptoms  like  those  from  which  this 
patient  has  suffered.  The  discoloration  of  the  skin  is  usually  more 
marked  than  that  here  described,  but  as  it  is  well  known  that  Addison's 
disease  can  occur  without  any  pigmentation  at  all,  it  is  well  always 
to  remember  the  disease  in  any  differential  diagnosis  of  cases  character- 
ized ])y  extreme  weakness  of  obscure  origin. 

Outcome. — The  face  and  hands  were  a  good  deal  darker  colored 
than  the  rest  of  the  body;  there  was  no  increase  at  the  body  folds. 

In  the  mouth  was  a  small  jxitch  of  dark-ljrown  color  on  the  inside 
of  the  cheek,  near  the  corner  of  the  mouth,  also  some  clusters  of  minute 
brownish  points  on  the  inside  of  the  cheeks  near  the  junction  of  the 
teeth,  and  a  few  on  the  hard  palate.  The  patient  looked  like  one  in 
the  last  stages  of  malignant  disease  or  tuberculosis.  At  times  he  would 
suddenly  feci  much  l)ctter. 

The  patient  was  ])ut  on  forced  feeding  by  mouth  and  rectum- 
whisky,  I  ounce  every  four  hours,  strychnin.  -;^^  grain  every  four  iiours 
and  seemed  better  until  the  fourth  of  Xovcm])er,  when  he  (lc\eloped 
fever  and  chill,  became  delirious,  and  soon  died. 


538  DIFFERENTIAL  DIAGNOSIS 

Autopsy  showed  tuberculosis  of  the  adrenal  glands;  obsolete  tuber- 
culosis of  the  apices  of  the  lungs. 
Diagnosis. — Addison's  disease. 

Case  279 

A  freight  truckman,  thirty-eight  years  old,  entered  the  hospital  July 
I,  1906.  He  had  formerly  used  alcohol  in  moderation,  but  had  used 
none  for  over  a  year  until  it  was  prescribed  by  a  doctor  during  the 
present  illness.  He  denies  venereal  disease,  and  has  been  well  until 
twelve  davs  ago,  when  he  began  to  feel  weak,  mean,  and  seedy.  Three 
days  ago  he  had  to  give  up  work  on  account  of  weakness,  night-sweats 
accompanied  by  constant  frontal  headache,  pain  all  over  him  (especially 
in  the  back),  anorexia,  nausea,  and  vomiting. 

Physical  examination  was  negative,  except  that  the  knee-jerks  and 
abdominal  reflexes  were  not  obtained.     The  nutrition  is  fair. 

Blood,  urine,  temperature,  pulse,  and  respiration  were  normal. 

Despite  his  weakness  and  prostration,  there  was  noticeable  during  the 
examination  an  unusual  degree  of  nervous  alacrity.  Any  direction 
given  him  was  executed  with  lightning  speed  and  almost  with  nolence. 

Discussion. — The  symptoms  of  the  onset  seem  like  those  of  an  acute 
infectious  disease,  especially  pneumonia  or  typhoid,  and  although 
fever  was  absent,  we  made  rigorous  and  repeated  search  for  visceral 
evidences  of  some  such  infection.  Nothing  came  to  light,  however, 
and  we  were  obliged  to  look  elsewhere  for  a  cause  of  the  symptoms. 
In  cases  of  this  kind  it  is  always  well  to  consider: 

(a)  Neurasthenia  or  some  other  type  of  psychoneurosis. 

(b)  Poisoning  by  morphin  or  some  other  drug. 

Though  abstractly  possible,  the  psychoneuroses  were  practically 
easy  to  exclude  when  we  were  face  to  face  with  this  burly,  lethargic, 
hard-working  wage-earner. 

Of  morphinism  there  was  no  hint,  either  in  the  history  or  in  his 
present  condition.  He  showed  none  of  the  vague  longings,  irritable 
complaints  of  widely  distributed  pain,  itching  about  the  face,  scars  of 
hypodermic  punctures,  pallor,  emaciation,  insomnia,  or  other  evidences 
of  the  morphin  habit. 

On  the  other  hand,  another  poison — alcohol — was  distinctly  sug- 
gested by  the  absence  of  knee-jerks,  when  considered  in  connection 
with  his  mental  state.  The  peculiar  alertness  and  alacrity,  shown  l^y 
alcohoHcs  immediately  previous  to  an  attack  of  delirium  tremens,  is 
difficult  to  convey  l)y  description,  but  easily  recognized  by  any  one 
who  has  once  or  twice  seen  it.     In  tlie  present  case  it  was  very  marked,  and 


WEAKNESS 


539 


was  associated  also  with  a  very  noticeable  smoothness  and  satiny  tex- 
ture of  the  skin,  a  sign  often  oj  great  value  in  patients  who  deny  al- 
coholism, but  present  other  evidences  which  make  us  suspect  it. 

Outcome. — Although  the  patient  indignantly  denied  any  recent 
alcoholic  excess,  he  began  to  show  the  nervous  symptoms  of  approach- 
ing delirium  tremens  two  days  after  his  entrance  to  the  hsopital,  and  in 
spite  of  considerable  doses  of  potassium  bromid.  These  symptoms 
abated,  however,  within  two  or  three  days,  when  he  was  able  to  go  home 
in  much  better  condition. 

Diagnosis. — Alcoholism. 

Case  280 

A  bridge-tender,  fifty-eight  years  old,  of  good  family  histor}-,  has 
had  "chronic  rheumatism,"  and  especially  "sciatic  rheumatism,"  in 
the  right  leg  at  irregular  intervals  for  ten  years  or  more.  Otherwise 
he  has  always  been  well  and  strong,  and  his  habits  have  been  good. 

Ten  months  ago  he  began  to  notice  a  weakness  so  marked  that  at 
times  he  came  near  fainting.  This  weakness  was  most  noticeable  in 
the  legs,  but  he  has  felt  tired  all  over.  For  the  last  six  weeks  he  has  felt, 
on  exertion,  a  rather  severe  pain  in  his  chest,  near  the  lower  part  of  the 
l^reast-bone,  accompanied  by  shortness  of  breath,  which  compels  him 
to  stop  whatever  he  is  doing.  The  pain  ceases  after  a  few  moments' 
rest.  Hearty  food  also  brings  on  this  pain,  which  comes  on  immediately 
after  eating  and  lasts  for  an  hour  or  more. 

He  has  no  cough,  no  vomiting;  is  usually  somewhat  constipated; 
the  bowels  move  once  in  two  or  three  days. 

Two  years  ago  he  weighed  250  pounds;  he  still  weighs  215.  He 
gets  up  three  or  four  times  at  night  to  pass  water. 

The  temperature,  pulse,  res])iration,  urine,  and  blood-pressure  all 
were  normal.  The  heart  showed  no  enlargement,  and  its  sounds  were 
of  fair  quality.  There  was  a  faint  systolic  murmur  at  the  a])ex,  trans- 
mitted a  few  inches  to  the  left;  no  accentuation  of  cither  sound  at  the 
base.  The  edge  of  the  liver  was  felt  two  inches  l)cl()\v  the  costal  margin; 
the  abdomen  is  otherwise  negali\e,  likewise  the  lungs,  rellexes,  and 
extremities. 

Rectal  examination  showed  ])rominent  external  hemorrhoids,  ])ut 
no  evidence  of  l)leeding. 

Examination  of  the  stomach  with  a  gastric  tul)e  showed  nothing 
abnormal,  either  physically  or  chemically. 

The  red  ceils  were  2,520.000;  white  cells,  8000;  hemoL:lol)in,  30  ])er 
cent.;  differential  count  normal.     Hie  stained  specimen  showed  marked 


540  DIFFERENTIAL  DIAGNOSIS 

achromia,  very  slight  variations  in  the  size  of  the  red  cells,  but  nothing 
else  abnormal. 

Discussion. — The  history  of  sciatica  and  the  complaint  of  especial 
weakness  in  the  legs  naturally  lead  us  to  consider  peripheral  neuritis. 
No  such  diagnosis  can  be  made,  however,  when  the  reflexes  are  normal 
and  all  sensory  symptoms  are  absent,  as  in  this  case. 

Arteriosclerosis  must  occur  to  us  whenever  a  patient  of  fifty-eight 
complains  of  substernal  pain  and  general  weakness.  Possibly  there  is 
some  arteriosclerosis  in  this  patient,  but  I  do  not  see  that  we  can  be 
sure  of  it  or  that  we  can  connect  it  with  his  present  symptoms,  since  his 
blood-pressure  is  low,  his  heart  negative,  and  symptoms  of  stasis  absent. 

But  for  the  blood-examination  this  patient  would  present  almost 
precisely  the  picture  of  pernicious  anemia;  even  the  substernal  pain, 
which  he  complains  of,  is  sometimes  seen  in  that  disease,  apart  from 
arteriosclerosis  or  nephritis.  The  blood-picture,  however,  is  that  of 
secondar}'  anemia,  and  compels  us  to  make  a  most  careful  search  for  its 
cause. 

That  search  should  be  directed  so  as  to  ascertain  whether  syphilis, 
malignant  disease,  hepatic  cirrhosis,  or  any  disease  involving  hemor- 
rhage is  present.  All  these  except  the  last  could  easily  be  excluded, 
but  in  \"iew  of  past  experience  I  always  look  with  particular  care  for 
evidence  of  hemorrhoids  when  the  problem  is  to  find  the  cause  for  the 
anemia  of  a  middle-aged  patient.  I  recollect  three  persons  suffering 
from  anemia  of  unknown  cause  and  totally  unaware  of  any  trouble 
from  piles,  which,  nevertheless,  turned  out  subsequently  to  be  the 
source  of  frequent  long-standing  hemorrhages.  In  all  these  cases 
the  anemia  was  cured  by  treating  the  piles  and  stopping  the  hemorrhage. 
The  same  turned  out  to  be  true  in  the  present  case,  the  moral  of  which 
is  that  careful  examination  of  the  rectum  with  a  speculum  should  always 
be  made  when  we  are  searching  for  the  cause  of  an  obscure  anemia. 

Outcome. — It  was  learned  subsequently  that  the  patient  had  had 
bleeding  piles  off  and  on  for  at  least  four  years.  For  some  unknown 
reason  he  omitted  to  mention  this  fact.  Operation  was  advised,  but 
refused. 

Diagnosis. — Secondary  anemia.     Piles. 

Case  281 

A  post-office  clerk  of  sixty-three  entered  the  hospital  November 
14,  1907.  He  was  in  the  hospital  first  in  1901  with  genito-urinary 
tuberculosis,  and  again  in  1904  for  stone  in  the  bladder.  He  seems 
to  have  reco\-ered  entirely  from  both  his  previous  troubles.     For  the 


WEAKNESS 


541 


l^jrrr»^j>^^ 


past  year  he  has  been  losing  strength  and  weight.  Twenty  years  ago 
he  weighed  196  pounds;  five  years  ago,  170;  one  year  ago,  167;  and 
now,  128.  From  July  ist  to  November  ist  of  this  year  he  was  unable 
to  work.  For  the  past  two  weeks  he  has  been  at  work  again,  but  had 
to  give  up  to-day.  He  has  no  other  symptoms  of  any  kind,  and  has 
noticed  no  pallor  or  pigmentation  of  the  skin. 

The  patient  is  somewhat  pale  and  much  emaciated.  A  systolic 
murmur  is  heard  at  the  apex,  but  not  transmitted.  The  heart  is  other- 
wise negative,  as  are  the  lungs.  The  arteries  are 
rough  and  tortuous.  The  pulse  appeared  to  be  one 
of  high  tension.     Hemoglobin,  25  per  cent. 

The  abdomen  and  extremities  show  nothing  ab- 
normal. The  course  of  the  temperature  is  seen  in 
the  accompanying  chart  (Fig.  136).  The  urine 
averaged  30  ounces  in  twenty-four  hours,  with  a 
specific  gravity  of  1012;  a  slight  trace  of  albumin 
was  found,  but  no  casts. 

Discussion. — In  looking  for  a  cause  for  the 
anemia  here  present  we  notice  that  the  kidneys  do 
not  seem  to  be  doing  much  work,  and  might  be 
rash  enough  to  assume  that  some  type  of  nephritis  is 
responsible  for  the  symptoms.  It  is  true  that 
nephritis  may  be  in  itself  the  cause  of  very  intense 
anemia,  but  is  there  any  sufficient  evidence  that 
this  man  has  a  nephritis  at  all  ?  The  total  solids 
excreted  are  certainly  very  deficient,  but  this  may 
be  the  result  merely  of  insufficient  food.  Although 
we  know  very  little  about  his  diet,  it  is  safe  to  assume  that  he  does 
not  cat  enough  to  give  him  the  normal  outj)ut  of  urinary  solids. 

Emaciation  is  at  least  as  im{)ortant  a  feature  as  the  anemia  in  this 
patient.  He  is  at  the  age  when  very  considerable  emaciation  often 
occurs  merely  as  the  result  of  the  aging  ])roccss — /.  <•..  of  arteriosclerosis. 
Such,  at  any  rate,  seems  to  me  the  reasonable  conclusion  as  we  obser\e 
the  ra])id  loss  of  weight  which  takes  place  in  a  large  ])roi)orlion  of 
elderly  ])crsons  without  any  corresponding  cliange  in  the  diet.  It  must 
be  confessed,  however,  that  the  c\i(lcnce  of  arteriosclerosis  in  this  patient 
is  not  conckisive.  Many  patients  whose  arteries  are  rough  and  tortuous 
turn  out.  postmortem,  to  have  \ery  little  arteriosclerosis,  and  the  high 
])ulse  tension  which  would  seem  to  \erify,  to  a  certain  extent,  the  hypothe- 
sis of  arteriosclerosis,  was  based  merely  on  digital  examination —a  most 
unreliable  procedure. 


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542 


DIFFERENTIAL   DIAGNOSIS 


Pernicious  anemia  is  probably  the  commonest  cause  of  an  extreme 
reduction  in  the  hemoglobin  percentage  at  the  age  of  sixty-three.  In 
most  cases  of  pernicious  anemia,  emaciation  is  comparatively  slight; 
sometimes  it  is  absent  altogether.  But  this  fact  does  not  by  any  means 
suffice  to  exclude  pernicious  anemia  in  this  case.  The  blood  must  be 
much  more  carefully  investigated. 

Outcome. — The  red  cells  were  found  to  number  863,000,  so  that 
the  hemoglobin,  though  very  low;  was  yet  relatively  high  (color  index, 
1.4).  The  leukocytes  numbered  4200,  58  per  cent,  of  which  were 
polynuclear,  with  41  per  cent,  of  lymphocytes  and  i  per  cent,  of  mast 
cells.  During  a  differential  count  of  200  cells,  four  normoblasts  and 
two  megaloblasts  were  found.  The  red  cells  were  of  huge  size,  deeply 
stained,  and  much  deformed.  Many  of  them  contained  basophilic 
gra.nulations  or  showed  diffuse  abnormal  staining  reaction. 

The  blood-pressure  was  only  100  mm.  Hg.  The  patient  rapidly 
failed  and  died  on  the  twenty-first. 

Diagnosis. — Pernicious  anemia. 

Case  282 

An  Irish  housewife  of  forty-two,  of  good  family  history,  had  malaria 
fifteen  years  ago;  a  still-born  child  last  May;  no  other  children  or  mis- 
carriages. 

Her  chief  complaint  at  the  present  time  is  of  weakness,  affecting 
especially  her  back.  She  entered  the  hospital  on  April  27,  1908.  Six 
months  previously  she  had  had  a  good  many  dizzy  spells,  with  insomnia 
and  much  nervousness.  At  that  time  she  was  five  weeks  in  a  hospital, 
but  no  diagnosis  was  made.  At  the  present  time  she  has  a  good  appetite 
and  sleeps  well. 

Her  catamenia  are  regular,  but  she  believes  herself  to  have  some 
pelvic  disease,  and  vomits  occasionally  without  relation  to  food. 

Physical  examination  shows  an  obese  woman,  with  a  dry  skin  and 
numerous  rose-colored  papules  scattered  over  the  front  of  the  chest  and 
abdomen.  Th'^^  course  of  the  temperature  is  seen  in  the  accompanying 
chart.  The  chest  and  abdomen  showed  nothing  abnormal.  The 
reflexes,  blood,  and  urine  were  negative.  Vaginal  examination  showed 
no  pelvic  disease. 

Discussion.— The  papules  here  described  had  all  the  characteristics 
of  rose  spots,  and  \\ould  have  passed  perfectly  well  for  the  exanthem 
of  typhoid  fever  had  any  pyrexia  been  present.  In  the  absence  of  fever 
no  obvious  ex])lanation  was  found  for  them.  It  may  be  worth  stating 
here  that,  even  in  febrile  conditions,  the  rose  spot,  although  most  valuable 


WEAKNESS 


543 


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as  confirmatory  evidence  of  typhoid,  is  by  no  means  pathognomonic  of 
that  disease.  The  typhoid  bacillus  is  not  the  only  germ  which  is  prone 
to  settle  beneath  the  skin  and  produce  the  hyperemic  area  known  as 
a  rose  spot.  I  have  seen  the  same  thing  in  pyogenic  sepsis  many  times, 
and  in  tuberculosis  once. 

The  patient  is  stated  to  be  obese.  Is  this  enough  to  account  for  her 
weakness?  Occasionally  one  sees  persons  for  whose  exhaustion  and 
incapacity  no  other  cause  can  be  found.  But  I  have  never  known  a 
patient  to  enter  a  general  hospital  on  this  account.  Further,  there  has 
been  no  special  increase  in  the  amount  of  fat  cuku. 

during  the  period  occupied  by  her  illness. 

Myxedema  is  sometimes  mistaken  for  obesity, 
and  often  causes  a  very  troublesome  weakness. 
In  the  present  case,  however,  we  have  no  good 
reason  to  beheve  that  myxedema  is  present. 
There  are  no  cutaneous  or  mental  symptoms, 
no  subnormal  temperatures,  nor  special  sen- 
sitiveness to  cold.  The  facial  expression  is  un- 
changed. 

If  physical  examination,  repeatedly  and  con- 
scientiously performed,  is  wholly  negative  in  a 
case  of  this  kind,  it  is  proper  to  investigate  the 
mental  condition  of  the  patient.  Subconscious 
fears  and  internal  tensions  may  be  enough  to 
account  for  all  the  troubles  of  which  this 
patient  com})lains,  though  we  should  never 
assume  anything  of  the  kind  until  e\'ery  other 
])ossibility  has  been  exhausted.  In  the  search 
for  a  ])svchic  cause  it  is  never  sufficient  to  ask  a  patient  such  a  question 
as,  "Are  you  worrying  al)out  anything?"  or  "Have  you  anything  on 
vour  mind?"  The  worries  which  do  the  most  harm  physically  are  those 
of  whicli  the  i)aticnt  is  ])artially  or  quite  unconscious.  Of  course,  the 
only  ])roof  that  our  diagnosis  is  right,  when  wc  believe  we  ha\e  succeeded 
in  drawing  out  of  the  depths  of  a  ])aticnt's  consciousness  some  sub- 
merged cause  of  internal  strife,  is  the  ])hysical  results.  If  immediate 
im])ro\emcnt  follows,  it  is  reasona])le  to  su])pose  that  we  have  hit  upon 
the  source  of  the  trouble. 

Outcome. — It  developed  later  that  after  her  child  was  born  and 
she  had  left  the  hosjntal,  she  was  told  that  she  was  "in  a  bad  way"; 
this  idea  fermented  in  her  mind  and  a])])arently  was  the  l)asi>  ot  her 
present  troubles. 


Fig.  137. — Chart  of  case 
282. 


544  DIFFERENTIAL   DIAGNOSIS 

During  two  weeks'  observation  she  seemed  to  be  perfectly  well, 
and  after  being  officially  reassured,  her  sensations  corresponded  to 
her  good  digestive  condition. 

Diagnosis. — Apprehension. 

Case  283 

An  Irish  chambermaid  of  twenty-two,  of  good  family  and  past  history, 
was  seen  December  i8, 1906.  She  came  to  the  United  States  four  months 
ago.  Her  menstruation  began  at  the  age  of  fifteen  and  has  always 
been  regular,  but  her  last  period  occurred  on  the  steamer  during  her 
passage  to  America, 

A  month  ago  she  began  to  feel  weak  and  unfit  for  work.  This 
weakness  was  accompained  by  a  palpitation  on  any  exertion  and  some- 
times by  faintness.  She  lias  been  very  constipated  all  through  her  sick- 
ness, but  has  had  no  vomiting  or  other  gastric  s\Tnptoms,  and  no  cough 
or  fever,  so  far  as  she  is  aware. 

On  examination  the  girl  is  well  nourished,  with  bright  red  cheeks, 
but  somewhat  pale  and  slightly  bluish  lips.  The  glands  are  palpable 
in  the  neck,  axillae  and  groins,  but  not  enlarged.  The  heart  seems  to 
be  of  normal  size,  its  action  regular,  but  there  is  a  rough  systolic  murmur 
heard  best  at  the  base  and  transmitted  to  the  left  axilla.  The  pulmonic 
second  sound  is  distinctly  louder  than  the  aortic. 

The  lungs  show  scattered  coarse  rales. 

Visceral  examination  is  otherwise  negative.  The  patient  weighed 
165^  pounds.  Her  pulse,  temperature,  respiration  and  urine  were 
normal  throughout  three  weeks'  observation. 

Discussion. — Could  this  girl  be  pregnant?  The  amenorrhea,  weak- 
ness, palpitation,  and  fainting  are  consistent  with  that  diagnosis,  which 
could  only  be  confirmed,  however,  in  case  the  uterus  was  found  to  be 
demonstrably  enlarged.  We  should  expect  also  some  gastric  disturb- 
ances and  changes  in  the  breasts.  Since  none  of  these  necessary  con- 
firmations appear  to  be  present,  we  must  look  for  some  other  cause  for  the 
amenorrhea. 

Vegetative  endocarditis  produces  general  weakness  without  localiz- 
ing symptoms.  It  had  been  considered  by  the  attending  physician 
on  account  of  the  rough  murmur  over  the  base  of  the  heart.  But  such 
a  diagnosis  needs  a  great  deal  more  evidence  before  we  can  be  content 
with  it.  The  pulmonic  second  sound,  though  louder  than  the  aortic,  did 
not  apijcar  to  be  abnormal,  and  there  was  no  fever,  chills  or  cardiac 
enlargement.  Regarding  the  leukocytes,  which  should  1)e  increased 
in  number  if  endocarditis  is  present,  we  have  as  yet  no  information. 


WEAKNESS 


545 


Cases  of  early  tuberculosis  often  have  a  history  very  much  like  this, 
and  one  should  always  examine  the  pulmonary  apices  with  especial  care 
in  such  a  case.  But  without  fever,  loss  of  weight,  gastric  disturbances 
or  cough  we  should  not  be  warranted  in  entertaining  any  further  the 
hypothesis  of  tuberculosis,  nor  in  suggesting  it  to  the  patient  or  her 
family.  Diffuse  rales  in  both  lungs  are  not  what  we  expect  to  find  in 
early  tuberculosis,  except  in  the  miliary  form,  and  then  with  much 
more  virulent  sMnptoms. 

If  the  patient  were  pale,  we  should  naturally  suspect  chlorosis. 
Everything  else  in  the  case  seems  consistent  with  that  idea.  Can  a 
patient  with  bright  red  cheeks  have  chlorosis  or  any  other  form  of 
anemia?  Most  certainly,  and  it  is  for  this  reason  that  I  have  intro- 
duced the  case.  Man}'  Hke  it  are  overlooked,  I  believe,  because  we 
have  not  the  habit  of  making  routine  hemoglobin  estimations.  The 
color  of  the  face  is  no  guide.  The  majority  of  pale  people  are  not 
anemic,  and  many  anemics  are  not  pale. 

Outcome. — The  red  cells  are  3,364,000;  white  cells,  3200;  hemo- 
globin, 35  j)er  cent.  The  stained  specimen  shows  marked  achromia,  no 
nucleated  cells,  no  abnormal  staining  or  abnormal  shapes.  The  dif- 
ferential count  is  also  normal. 

It  was  subsequently  learned  that  before  coming  to  this  country 
she  had  always  been  used  to  out-of-door  life,  though  during  her  work 
here  she  had  been  closely  confined. 

Under  Blaud's  pill,  10  grains  three  times  a  day,  the  red  cells  had 
risen  by  the  fifth  of  Januar}'  to  4,400,000,  the  hemoglobin  to  60  per  cent., 
and  the  girl  felt  entirely  well. 

Cascara  was  needed  at  the  beginning  of  tlie  treatment,  ]:)ut  not  after 
the  first  week. 

Diagnosis. — Chlorosis. 

Case  284 

A  Syrian  thirty-sc\en  years  old  entered  the  hos])ital  June  27,  1906. 
He  has  had  many  touches  of  malaria,  and  takes  three  wliiskies  a  day. 
Otherwise  his  history  was  not  notable  until  seven  months  ago,  when 
he  began  to  lose  strength  and  got  run  down.  For  the  ])ast  three  months 
he  has  been  ra])icilv  i^rowinsi;  weaker.  At  no  time  has  lie  had  any  j)ain 
or  other  localizing  symptoms  except  at  the  very  beginning  of  his  iUness, 
when  he  liad  a  rather  indefinite  jniin  in  the  right  shoulder  and  right 
axilla.  This  ])asse(l  off  within  a  few  weeks,  but  has  returned  au'aii^  of 
late. 

He  has  no  cough  and  no  (lys])nea,  but  within  the  past  Nvcek  he  has 


546 


DIFFERENTIAL   DIAGNOSIS 


taken  \  grain  of  morphin  every  night  to  make  him  sleep.  For  four  or 
five  davs  he  has  been  in  bed.  Two  weeks  ago  he  noticed  for  the  first 
time  that  his  feet  were  swollen. 

On  examination  the  man  was  emaciated.  The  right  chest  was  flat 
in  front  below  the  third  rib  and  below  the  spine  of  the  scapula  above. 
Breath-sounds  and  voice-sounds  were  absent  over  the  same  area. 

The  heart's  impulse  was  in  the  fifth  space,  and  reached  if  inches 
outside  the  nipple-line.     The  right  border  could  not  be  determined. 
The   pulmonic    second   sound    was    accentuated. 
There  were  no  murmurs.     Blood-pressure,  140. 

The  abdomen  was  held  rigidly  throughout.  It 
was  tympanitic,  not  tender.  There  was  soft  edema 
of  the  lower  legs  and  feet,  also  some  over  the 
sacrum.  The  white  cells  were  15,000;  hemoglobin, 
85  per  cent.  The  course  of  the  temperature  is  seen 
in  the  accompanying  chart. 

Discussion. — The  essential  features  of  the  case 
are:  fever,  weakness,  displacement  of  the  cardiac 
apex,  edema  of  the  feet,  and  apparently  fluid  in 
the  right  chest. 

Pleurisy  is  naturally  our  first  thought,  but  we 
are  puzzled  by  the  absence  of  pain,  cough,  or 
dyspnea,  and  by  the  presence  of  swelled  feet.  Can 
the  latter  symptoms  be  the  result  of  a  pleurisy,  or 
must  we  suppose  that  both  the  swollen  feet  and 
the  thoracic  fluid  are  the  results  of  some  common 
cause,  perhaps  disease  of  the  heart  or  kidney? 
If  the  heart  is  diseased,  we  should  expect  either  a  murmur,  a  change 
in  blood-pressure,  an  arhythmia,  or  some  other  evidence  besides  dropsy. 
Further,  it  is  difficult  to  explain  the  fever  as  the  result  of  heart  disease 
unless  there  is  a  vegetative  endocarditis,  in  wMch  case  there  should  be 
a  murmur,  though  this  is  not  invariable. 

Xo  more  positive  evidence  can  be  obtained  without  tapping  the 
chesL  The  characteristics  of  the  fluid  thus  presumably  to  be  obtained 
should  decide  the  question.  Meantime  it  may  be  suggested  that  in 
children  such  a  grou])  of  symptoms  would  be  clearh"  indicative  of  em- 
pyema. What  lia])[)ens  fre(|uently  in  childrea  may  occur  now  and  ther 
in  adults. 

Outcome. — Exploratory  puncture  showed  foul  pus  on  the  twenty- 
eighth.  Next  da}-  a  rilj  was  resected,  and  several  pints  of  the  same 
fluid  remo\ed.     The  pus  showed  no  growth  on  ordinary  culture-media. 


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case  284. 


WEAKNESS 


547 


The  patient  did  well  for  the  week  following  operation,  and  went  home 
with  a  small  discharging  sinus.  His  further  progress  could  not  be 
traced. 

Diagnosis. — Empyema  [tuberculous  ?]. 

Case  285 

A  boy  of  four  years,  with  good  family  history,  entered  the  hospital 
May  27,  1908.  He  had  always  been  well  until  nineteen  days  ago,  when 
he  complained  of  being  tired,  and  seemed  listless  and  disinclined  to  play. 
Soon  after  this  he  began  to  be  feverish,  especially  at  night. 

For  the  past  fifteen  days  he  has  been  in  bed.  At  no  time  has  he 
complained  of  any  pain.  His  appetite  has  been  good,  his  bowels  regular, 
and  he  sleeps  well.  He  has  had  a  little  dry  cough  for  a  week.  (The 
course  of  the  temperature  is  seen  in  the  accompanying  chart.  Fig.  139.) 


Fi^.  139. — Chart  of  case  285. 

Physical  examination  shows  a  well-nourished  child,  witli  |>ink 
cheeks  and  a  freckled  face.  His  left  tonsil  is  enlarged,  his  throat  some- 
what reddened.  The  heart's  impulse  is  in  the  fourth  interspace,  just 
outside  the  nipple-line.     The  organ  seems  otherwise  normal. 

The  right  chest  in  front  is  Hat  below  the  fourth  interspace,  tiie  line 
of  llatness  rising  in  the  axilla,  so  that  it  reaches  to  the  toj)  of  the  chest 
behind.  Respiration  is  normal  oxer  the  left  chest,  harsh  in  the  front 
of  the  right  chest,  above  the  line  of  llatness;  below  that  it  i^  nearly 
absent. 

Just  below  the  midscapular  Ie\el  behind,  there  is  a  s])ot  of  l)ron(hial 
breathing   and   a   few   crackling   rales.     \'oice-soun(l>  are   sh^Oitly   in- 


548  DIFFERENTIAL   DIAGNOSIS 

creased  at  this  point.  Elsewhere  they  are  absent.  The  edge  of  the 
liver  is  felt  one  finger's-breadth  below  the  ribs. 

Discussion. — One  could  hardly  make  a  mistake  regarding  the 
diagnosis  in  this  case  if  he  })laced  his  reliance  upon  physical  signs. 
What  I  desire  specially  to  point  out  is  the  misleading  character  of  the 
history.  The  child  has  no  pain  in  the  side,  almost  no  cough,  no  dyspnea, 
nothing  to  call  one's  attention  rather  to  one  part  of  the  body  than  to 
another. 

Relying  on  the  physical  signs,  we  cannot  doubt  that  there  is  fluid 
in  the  right  chest.  The  small  spot  of  bronchial  breathing  near  raid- 
scapula  is  not  in  the  least  in  contradiction  to  this  diagnosis.  Indeed, 
we  generally  hear  bronchial  breathing  in  some  part  of  the  chest  of  a 
young  child  when  fluid  is  present  in  large  amounts.  Pneumonia,  the 
only  other  disease  which  we  could  consider  at  all,  never  has  so  insidious 
an  onset  or  so  prolonged  a  course  in  young  children. 

When  we  know  that  a  child's  chest  contains  fluid  and  have  no  reason 
to  suspect  disease  of  the  heart  or  kidney,  we  may  feel  practically  certain 
that  empyema  is  the  diagnosis.  Insidious  serous  effuson,  so  common 
in  adults  as  a  result  of  tuberculosis,  is  distinctly  rare  in  infancy,  while 
the  pneumococcus  infections  leading  to  empyema  are  common,  and 
present,  as  a  rule,  just  such  a  clinical  picture  as  I  have  here  reproduced. 

Outcome. — On  the  twenty-eighth  the  chest  was  opened,  with  the 
escape  of  lo  ounces  of  pus  teeming  with  a  growth  of  pneumococci.  The 
child's  convalescence  was  prolonged  and  often  interrupted  by  the  reten- 
tion of  pus  in  subsidiary  caA'ities,  owing  to  unsatisfactory  drainage. 
Recovery  was  ultimately  complete. 

Diagnosis. — Empyema. 

Case  286 

A  Scottish  salesman,  seventy  years  old,  of  good  familv  historv  and 
past  history,  entered  the  hospital  November  8,  1906.  He  gave  up 
work  six  months  ago  on  account  of  progressi\-e  weakness.  About  a 
month  later  he  noticed  that  gas  gathered  in  his  stomach  about  twenty 
minutes  after  eating,  causing  considerable  noise  and  some  nausea. 
He  has  at  no  time  any  pain.  Imt  has  gradually  become  weaker,  paler, 
and  more  short  of  breatli.  ^\'ithin  the  past  three  weeks  his  legs  have 
swollen;  his  skin  ha>  turned  yellow  and  itched.  Ten  months  ago  he 
weighed  195  pounds,  now  he  weighs  155. 

Examination  showed  ob^■ious  loss  of  weiglit;  skin  pale,  and  of  a 
yellowish  tinge;  no  demonstrable  jaundice,  the  color  l^eing  more  like 
that    of    pernicious   anemia.     The    heart    showed   a    systolic    murmur, 


WEAKNESS 


549 


audible  all  over  the  precordia  and  in  the  left  axilla.  The  sounds  were 
faint  and  distant.  There  were  no  evidences  of  enlargement  and  no 
irregularity.  Visceral  examination  was  otherwise  negative,  exce])t  for 
a  slight  puf&iess  of  the  face  and  hands,  and  a  moderate,  rather  brawny 
edema  of  the  lower  legs. 

The  red  cells  were  2,328,000;  white  cells,  5000;  hemoglobin,  25 
per  cent.  There  was  a  very  marked  serum  ring  around  the  blood- 
stain as  I  took  the  hemoglobin  test  by  the  Tallqvist  scale.  The  differen- 
tial count  showed  polynuclears,  59  per  cent.;  lymphocytes,  41  per  cent. 
The  red  cells  showed  very  marked  achromia,  moderate  deformities  in 
shape,  no  abnormal  staining  reactions,  no  blasts.  The  urine  was 
altogether  negative.  A  small  amount  of  brownish  material  which  gave 
a  positive  guaiac  reaction  was  found  in  the  fasting  stomach.  The 
organ  held  52  ounces,  and  after  a  test-meal  showed  no  free  HCl. 

Discussion. — Here  we  have  the  s\anptoms  of  ])crnicious  anemia 
but  the  blood-picture  does  not  correspond.  It  is  a  familiar  puzzle  and 
an  important  one.  As  a  result  of  a  fairly  extensi\e  experience  in  dealing 
with  this  particular  problem  I  think  it  may  be  stated  that  it  is  the  part 
of  wisdom  to  follow  the  indications  of  the  blood-examination  in  such 
cases.  Primary  anemia  does  not  produce  a  l3lood-])icture  like  that  here 
described  in  patients  of  this  age.  The  most  distinctive  features  are  the 
achromia  and  the  low  color  index. 

Assuming,  then,  that  we  are  dealing  with  secondary  anemia,  what  is 
its  cause?  In  men  of  this  age  severe  secondary  anemia  is  produced 
usuallv  by  cancer,  syjjhilis,  or  hemorrhage.  The  anemia  of  nephritis 
or  of  cirrhosis  usually  occurs  in  younger  persons.  Since  we  have  no 
evidence  whatever  either  of  syj)hilis  or  hemorrhage,  cancer  is  the  most 
])robable  diagnosis.  But  what  is  the  seat  of  the  tumor?  Such  slight 
indications  as  we  possess  seem  to  ])oint  to  the  stomach.  The  recovery 
of  a  material  reacting  positively  to  the  guaiac  test,  the  absence  of  hydro- 
chloric acid,  the  slight  enlargement  of  the  stomach,  the  nausea  and 
flatulence  tend  to  conllrm  this  indication. 

The  case  is  of  sj)ecial  interest  because  of  the  al)sence  of  pain  and 
vomiting.  It  tends  to  substantiate  the  old  rule,  which  bids  us  sus|)ect 
gastric  cancer  whenc^-er  a  patient,  |)re\iously  free  from  digestive  dis- 
turbances ])cgins  in  later  life  to  have  any  gastric  sym])toms,  however 
slight. 

Outcome. — Tjie  patient  was  given  forced  feeding  and  oxygen  by 
rectum  in  the  hope  of  inhibiting  the  growth  of  anaerobic  bacteria,  Init 
on  the  fourteenth  of  X()\enil)er  he  was  so  weak  that  he  could  not  walk 
alone.     The    blood  examination  then  showed:     Red    cells,     1,820,000; 


550 


DIFFERENTIAL  DIAGNOSIS 


white  cells,  32CX);  hemoglobin,  12  per  cent.  The  stained  specimen 
showed  essentially  the  same  as  the  previous  examination. 

The  patient  died  on  the  seventeenth.  Autopsy  showed  a  large, 
cauliflower  growth  at  the  pylorus,  almost  obstructing  its  lumen;  car- 
cinoma histologically. 

Diagnosis. — Gastric  cancer. 

Case  287 

An  Italian  housewife,  fifty  years  old,  entered  the  hospital  June  17, 
1907.  She  began  to  complain  four  weeks  ago  of  weakness  and  fatigue. 
It  was  also  noticed  that  she  passed  ver}-  little  urine. 

For  three  weeks  she  has  been  in  bed,  complaining  mostly  of  weakness, 
accompanied  by  anorexia,  insomnia,  and  constipation.  Her  mouth  is 
dry  and  she  is  very  thirsty.  There  is  a  dull,  constant  epigastric  pain. 
Last  week  she  vomited  twice  small  quantities  of 
green  fluid.  She  has  no  headache;  her  eye-sight 
is  good.     The  urine  continues  scanty. 

On  examination  the  patient  is  found  to  be  some- 
what emaciated.  Her  chest  shows  nothing  abnor- 
mal except  a  few  crackles  and  squeaks  in  the  lower 
part  of  each  lung. 

The  abdomen  is  protuberant,  the  umbilicus 
pushed  out,  and  there  is  shifting  dulness  in  the  flanks. 
The  condition  of  the  epigastrium  is  shown  in  the 
accompanying  diagram,  and  the  temperature  in  the 
accompanying  chart  (Fig.  140). 

The  blood  and  urine  show  nothing  abnormal. 
The  circumference  of  the  abdomen  at  the  level  of 
the  navel  is  80  cm. 

Discussion. — Cirrhosis  of  the  liver  was  the  "snap 
diagnosis"  in  this  case,  suggested,  of  course,  by  the 
insidious  onset  of  extensive  ascites.  Although  this 
disease  cannot  be  excluded  from  consideration,  there 
are  a  number  of  points  against  it.  The  most  important  is  the  patient's 
pain,  a  symptom  of  which  we  hear  practically  nothing  in  cirrhosis. 
Further,  Italian  wine,  which  is  all  that  this  patient  has  taken,  does  not 
often  produce  cirrhosis.  Finally,  the  surface  of  the  liver,  which  is 
stated  to  be  rough  on  palpation,  is  not  characteristic  of  cirrhosis  from 
the  clinical  point  of  view.  The  hob-nails  of  the  hob-nail  liver  are  almost 
never  to  be  felt  through  the  abdominal  wall.  I  have  known  many 
cases  where  they  were  felt,  but  not  one  of  these  cases  turned  out  to  be 


140. — Chart    of 
case  287. 


Fif^.  141. — liiidings  in  a  case  characterized  chiefly  1)y  weakness  and  swollen  V)ellv  (four 

weeks'  duration). 


WEAKNESS  551 

cirrhosis.  The  supposed  hob-nails  proved  to  be  nodules  of  fat  in  the 
abdominal  wall  or  irregularities  due  to  cancer  or  syphilis. 

The  course  of  the  disease  seems  very  short  and  rapid  for  syphilis. 
The  transition  from  perfect  health  to  great  prostration,  with  ascites, 
anorexia,  and  vomiting  is  rarely  brought  about  by  syphilis  within  four 
weeks.  Of  course,  it  may  well  be  that  the  history  is  inaccurate,  especially 
as  it  was  obtained  through  an  interpreter.  If  we  disregard  the  history, 
the  chief  evidence  against  syphilis  is  the  absence  of  any  luetic  lesions 
in  other  parts  of  the  body.  Without  the  therapeutic  test,  however,  it 
is  impossible  positively  to  exclude  syphilis  in  this  case. 

Tuberculous  peritonitis  is  not  common  at  this  age,  rarely  produces 
so  much  prostration,  and  would  not  explain  the  enlargement  of  the 
liver  and  spleen,  or  what  we  take  to  be  such.  Cancer  of  the  liver  would 
explain  most  of  the  symptoms,  and  would  account  for  the  rapid  march 
of  the  malady.  It  is  surprising,  however,  that  no  more  marked  gastric 
symptoms  are  complained  of.  Hepatic  cancer  usually  shows  itself  as 
a  later  development  in  an  illness  characterized  by  months  of  severe 
digestive  disturbance.  Possibly  the  cancer  may  have  originated  in 
some  ''silent,"  deep-seated  organ,  w^hence  it  was  extended  by  metastasis 
to  the  liver. 

Banti's  disease  is  always  to  be  suspected  when  an  Italian  is  found 
to  be  sulTering  from  enlargement  of  the  liver  and  spleen  with  ascites. 
It  must  be  admitted,  however,  that  the  clinical  picture  of  Banti's  disease 
has  seldom  been  clearly  recognized  except  by  Italian  writers.  It  is 
essential,  at  all  events,  that  we  should  be  able  to  demonstrate  an  enlarge- 
ment of  the  spleen  preceding  by  a  consideral^lc  period  the  onset  of 
ascites  and  hepatic  hyf)ertro])hy.  Nothing  of  the  kind  can  be  shown 
in  the  |)resent  case. 

The  most  reasona1)le  diagnosis,  therefore,  a})pears  to  be  cancer  of  the 
liver,  origin  unknown. 

Outcome. — June  i8th  it  was  learned  that  she  had  rcceiNcd  large 
doses  of  mercury  and  potassium  iodid  before  entrance,  hence  this  clue 
was  not  followed  up  any  furtluT.  The  ])atient  died  on  the  twenty- 
second.  Auto})sy  showed  primarv  cancer  of  the  li\er  with  nietastascb 
in  the  mesenteric  glands,  spleen,  pancreas,  lungs  and  thyroid. 

Diagnosis. — Cancer  of  the  liver. 

Case  288 

A  Jewish  married  woman,  thirty-four  years  old.  was  lir.-t  seen 
February  4,    1Q07.     Her  lather  died  of    kidney  di,sea>e;    her  famil\- 


552  DIFFERENTIAL   DIAGNOSIS 

history  is  otherwise  good.  She  had  chlorosis  when  she  was  seventeen. 
She  has  had  three  children,  the  youngest  five  years  old. 

For  eighteen  months  she  has  felt  weak,  and  in  that  time  she  has  lost 
about  30  pounds.  Her  ai)petite  has  been  poor  throughout  this  period. 
At  times  she  has  been  feverish.  She  often  has  a  bitter  taste  in  her  mouth 
after  eating.  Four  weeks  ago  she  had  a  severe  left-sided  headache; 
since  then  she  has  heard  roaring  noises  in  her  head,  and  has  felt  still 
weaker  than  before. 

Two  weeks  ago  she  had  two  similar  attacks  within  a  week,  and 
the  headache  has  been  continuous  for  the  last  five  days.  With  each 
of  these  attacks  of  headache  she  has  vomited,  but  there  has  been  no 
other  ])ain.  When  her  eyes  were  examined  recently  at  the  Eye  and  Ear 
Infirmary  they  were  found  to  be  normal.  Throughout  the  eighteen 
months  of  her  illness  she  has  had  diarrhea  alternating  with  constipation. 

The  patient  was  poorly  nourished,  the  skin  brightly  colored.  Visceral 
examination  was  wholly  negative,  as  was  the  blood  examination.  The 
urine  was  free  from  albumin  and  casts;  twenty-four-hour  amount 
normal. 

Discussion. — Weakness  and  loss  of  weight  with  headache  and 
digestive  symptoms  are  complained  of  by  innumerable  Jewesses  of  this 
age  without  our  being  able  to  discover  any  more  definite  cause  than 
their  self-starvation  and  a  psychoneurotic  constitution.  If  Ihe  physical 
examination  is  wholly  negative  and  no  drug  habits  can  be  discovered, 
the  case  will  have  to  be  treated  on  this  basis. 

We  must  first  make  sure,  however,  that  nothing  of  any  importance 
has  been  omitted  from  our  physical  examination.  Are  we  quite  certain 
that  no  hints  of  larval  hyperth}Toidism  are  to  1)e  found?  No  tremor, 
tachycardia,  profuse  sweating  without  cause  or  slight  thyroid  enlarge- 
ment? All  these  signs  were  searched  for  in  the  present  case,  with 
negative  results. 

One  all-essential  point,  however,  is  omitted  in  the  account  of  the 
case  printed  above,  because  it  was  absent  from  the  record  presented  to 
me  when  I  saw  the  case  in  consultation.  There  is  no  record  of  the 
test  for  sugar  nor  of  the  s])ecific  gravity  of  the  urine,  which  turned  out 
to  be  T040. 

Outcome. — Fi\e  and  a  half  per  cent,  of  glucose  was  found  in  the 
urine.  Jn  the  course  of  a  month,  howcA'cr,  this  disappeared  under  a 
diet  of  increased  fats  and  diminished  carbohydrates.  The  headache, 
which  had  been  throughout  her  chief  complaint,  disappeared  as  soon 
as  the  urine  became  sugar-free.  In  the  course  of  the  month  under  my 
observation  she  gained  six  pounds. 

Diagnosis. — Diabetes  mellitus. 


WEAKNESS  553 


Case  289 


A  school-boy  of  fifteen  was  first  seen  on  November  28,  1907.  His 
family  history  is  good,  and  he  has  always  been  well  until  three  weeks 
ago,  when  he  began  to  complain  of  weakness,  headache,  vertigo,  and 
sHght  nausea. 

Six  weeks  ago  he  weighed  99  pounds;  now  he  weighs  81.  His 
appetite  is  good,  his  bowels  regular,  and  there  is  no  vomiting. 

Physical  examination  shows  emaciation  and  mental  dulness. 

The  edge  of  the  liver  is  felt  on  inspiration.  Physical  examination, 
including  the  blood,  is  otherwise  negative.  The  urine  is  pale,  its  quantity 
from  3500  to  5000  c.c.  in  twenty-four  hours,  the  specific  gravity  never 
far  from  1030;  amount  of  sugar,  5.5  per  cent.,  gradually  rising  to  7.5 
per  cent,  during  the  five  weeks  of  his  stay  in  the  hospital. 

Discussion. — This  case  is  introduced  merely  as  a  further  exempli- 
fication of  the  fact  that  diabetes  may  occur  without  any  of  the  cardinal 
symptoms  on  which  we  often  rely  for  diagnosis.  This  boy  complained 
of  no  thirst,  had  no  increase  of  appetite,  and,  so  far  as  he  knew,  no 
polyuria.  The  diagnosis  was  simple  enough  as  the  result  of  a  routine 
examination,  including,  as  all  such  examinations  should,  a  test  for  sugar. 

Of  some  interest,  1  think,  is  the  outcome  of  the  treatment,  which, 
though  it  sufficed  merely  to  prolong  the  boy's  life  for  a  month,  un- 
doubtedly did  accompHsh  as  much  as  this.  Such  a  res])ite  is  sometimes 
of  very  great  importance  when  a  relative  wishes  to  come  from  a  distance 
or  when  a  financial  matter  has  to  be  finished  up. 

T  may  call  attention  also  to  the  convulsions  which  occurred  as  a 
j)art  of  the  terminal  acidosis.  Diabetes  is  not  often  mentioned  among 
the  ])Ossible  causes  of  convulsions,  because  there  is  so  rarely  any  difii- 
culty  in  recognizing  sj)asms  of  this  type,  occurring  as  they  do  at  tlie 
end  of  a  prostrating  illness,  the  nature  of  whicii  is  not  likely  to  ha\-e 
been  in  doubt.  When  a  convulsion  occurs  "out  of  a  clear  sky''  in  a 
])atient  not  known  j^reviously  to  be  ill,  it  practically  never  turns  out  to 
be  due  to  diabetes. 

The  purpura  noted  in  the  outcome  was  doubtless  of  the  cachectic 
tyi)e. 

Outcome.  As  he  showed  every  sign  of  imj)ending  coma  at  entrance. 
he  was  saturated  as  rapidly  as  possibk'  with  sodium  bicarbonate,  giwn 
both  by  mouth  and  intravenously.  Sodium  bicarbonate.  250  c.c.  ot  a 
2.^,  per  cent,  solution,  was  given,  and  next  day  350  c.c.  ot  a  5  per  cent, 
solution  of  glucose  was  administered  intra\enously.  This  was  followed 
by  a  very  marked  imj)rovement. 


554 


DIFFERENTIAL    DIAGNOSIS 


On  account  of  the  very  marked  acidosis  the  patient  was  given  an 
unmodified  diet,  the  bowels  kept  open  by  enemata,  and  his  appetite 
stimulated-  by  bitter  tonics.  He  was  kept  out-of-doors  daily,  well 
wrapped  up,  in  bed. 

December  loth  the  diet  was  slightly  restricted,  omitting  starchy 
soups,  though  cereals,  bread,  milk  and  potatoes  were  given  without 
restriction.  Chewing-gum  was  allowed  on  his  request,  and  gave  much 
relief  to  the  dryness  of  the  mouth. 

Impending  coma  was  again  relieved  on  the  fifteenth  by  a  treatment 
similar  to  that  previously  given,  but  it  seemed  wise  not  to  attempt 
further  to  restrict  the  diet. 

He  steadily  lost  weight  and  strength,  and  any  exertion  made  him 
drowsy. 

On  the  thirtieth  numerous  purpuric  spots  appeared  on  the  trunk, 
arms  and  legs,  and  he  began  to  have  drowsiness,  which  rapidly  in- 
creased to  complete  coma,  after  which  he  had  a  series  of  general  clonic 
convulsions  lasting  from  thirty  to  sixty  seconds  each.  At  midnight  he 
died. 

Diagnosis.— Diabetes  mellitus. 

Case  290 

An  Irish  painter  of  thirty  entered  the  hospital  November  25,  1907. 
His  mother  died  of  cancer,  and  he  has  lost  one  sister  of  consumption. 
He  is  a  hard  drinker  every  Saturday,  rarely  drinking  during  the  week. 
He  had  gonorrhea  three  times,  but  denies  syphilis. 

For  six  weeks  he  has  complained  of  weakness  in  his  legs  and  back — 
he  says  his  legs  won't  hold  him  up.  His  joints  are  lifeless  and  he  cannot 
go  upstairs.  There  is  no  swelling  of  his  joints,  and  he  has  no  pain 
except  on  stretching  the  muscles.  He  has  lost  no  weight.  His  appetite 
is  good,  and  he  feels  well  except  for  the  above  complaint.  He  quit 
work  two  weeks  ago,  but  has  not  been  in  bed. 

Physical  examination  shows  slight  irregularity  of  both  pupils,  with- 
out any  other  abnormality  there.     There  is  no  lead  line. 

Tlie  heart  is  slow — 60  to  the  minute,  with  a  prolonged  diastolic 
pause.  The  artery  walls  are  firm,  but  not  nodular;  lungs  normal, 
abdomen  rather  s])astic,  not  otherwise  remarkable.  There  is  well- 
marked  left  varicocele. 

The  knee-jerks  are  absent  even  on  reenforcement.  Kernig's  sign 
present  on  the  right;  well-marked  Romberg  sign;  superficial  reflexes 
lively;  no  Babinski;  temperature,  pulse,  respiration;  and  urine  are 
normal. 


WEAKNESS  555 

Discussion. — Most  patients  who  come  to  us  complaining  of  wealc- 
ness  in  the  legs  have  some  disease  of  the  nervous  system.  Occasionally 
a  case  of  diabetes  or  of  cardiac  trouble  brings  this  symptom  into  the 
foreground,  but,  as  a  rule,  all  general  diseases  outside  the  central  ner\ous 
system  have  some  chief  complaint  or  complaints  other  than  weakness. 

Among  diseases  of  the  nervous  system  some  type  of  neuritis  is 
suggested  because  the  pupils  are  normal,  the  reflexes  diminished,  and 
the  symptoms  bilateral.  The  occupation  of  the  patient  naturally  ])re- 
judices  us  in  favor  of  lead-poisoning,  but  as  there  is  no  lead  line,  no 
colic,  no  special  in\olvement  of  the  extensor  muscles  (toe-drop),  we 
are  inclined  to  canvas  the  other  possible  causes  of  neuritis  first. 

As  an  alcoholic  he  has  a  perfect  right  to  alcoholic  neuritis,  though 
we  see  no  special  reason  why  it  should  come  on  now  rather  than  sooner. 
Most,  if  not  all,  cases  of  alcoholic  neuritis,  however,  present  some 
sensory  symptoms.     This  patient  has  none. 

Tabes  dorsalis  is  ver\'  unlikely  on  account  of  the  normal  reaction 
of  the  pupils  and  the  entire  absence  of  sensor}^  symptoms  such  as 
usually  occupy  the  foreground  in  tabes. 

One  possibly  decisive  test  has  been  omitted — blood  examination. 
Alcoholic  neuritis  rarely  if  exei  produces  any  marked  basophilic  stip- 
pling of  the  red  cells;  saturnine  neuritis  practically  always  does.  To 
this  question,  therefore,  it  is  reasonable  next  to  turn  our  attention. 

Outcome. — Blood  examination  showed  hemoglobin,  70  per  cent.; 
leukocvtes,  5500.  In  the  stained  smear  the  red  cells  exhibited  marked 
achromia  and  a  great  deal  of  stippling,  but  no  other  abnormalities. 

Under  })otassium  iodid — 10  grains  thrice  daily — the  patient  began  to 
impro\e  at  once,  and  by  the  thirteenth  of  December  could  walk  fairly 
well,  though  a  slight  exertion  put  him  out  of  breath. 

Diagnosis. — Lead-poisoning  (?). 

Case  291 

A  married  woman,  forty-three  years  old,  with  an  excellent  family 
history,  past  history,  and  good  habits,  entered  the  hos])ital  October  13, 
1006.  She  had  always  been  well  until  a  }ear  ago,  when  she  noticed 
that  she  was  gradually  growing  weak.  She  had  no  ])ain  anywhere; 
her  a])])etite  remained  good  and  her  bowels  regular;  but  some  montlis 
later  she  noticed  that  tlie  abdomen  was  increasing  in  size  and  that  she 
was  short  of  breath  on  exertion.  At  this  time  she  was  much  annoyed 
by  noises  in  her  left  ear  and  by  attacks  of  vertigo.  Throughout  the 
past  year  her  weakness  has  steadily  increased  and  is  her  only  com- 
plaint at  the  present  time. 


^^6  DIFFERENTIAL   DIAGNOSIS 

Four  years  ago  she  weighed  i6o  pounds,  now  she  weighs  117. 
On  examination  the  patient  is  somewhat  pale,  but  the  hemoglobin 
shows  70  per  cent.     She  is  well  nourished. 

The  heart  is  negative,  save  for  a  soft  systolic  murmur,  best  heard 
in  the  third  left  interspace,  and  not  transmitted.  The  vessels  of  the 
neck  pulsate  rather  strongly.  The  lungs  are  entirely  negative.  The 
abdomen  shows  a  marked  prominence  on  the  left  side,  and  dulness  as 
shown  in  the  accompanying  diagram  (Fig.  142). 

Discussion. — One  could  hardly  make  a  mistake  in  the  diagnosis 
of  this  case  unless  one  were  in  the  habit  of  relying  on  symptoms  rather 
than  on  the  results  of  physical  examination.  No  one  could  fail  to 
notice  the  abdominal  tumor  if  he  had  palpated  the  abdomen  with  any 
care.  No  one  with  any  knowledge  of  physical  examination  could  have 
any  doubt  that  that  tumor  was  due  to  splenic  enlargement. 

Splenic  enlargement  associated  with  such  evidences  of  anemia  as 
this  patient  presents  is  characteristic  of  three  diseases  seen  in  temperate 
cUmates,  and  among  those  who  have  never  visited  the  tropics.  The 
huge  "ague-cake"  of  chronic  estivo-autumnal  malarial  or  kala-azar 
need  not  be  considered  in  any  patient  who  has  never  been  out  of  New 
England.  Leukemia,  splenic  anemia,  and  syphilis  are  the  only  diseases 
which  we  need  to  consider.  Leukemia  can  be  instantly  recognized  by 
the  blood  examination.  Splenic  anemia  and  visceral  syphilis  may  be 
almost  indistinguishable  unless  other  evidence  of  syphilis  can  be  ob- 
tained from  the  history  or  in  the  physical  examination. 

Outcome. — Examination  of  the  blood  showed:  red  cells,  2,656,000; 
white  cells,  652,000.  Differential  count  showed  polynuclears,  54  per 
cent.;  myelocytes,  38  per  cent.;  eosinophiles,  3.5  per  cent.;  mast  cells, 
2.5  per  cent.;  lymphocytes,  2  per  cent. 

The  red  cells  wTre  well  stained  and  showed  no  special  abnormalities. 
This  blood-picture  did  not  change  appreciably  during  the  month  in 
which  the  patient  was  under  observation. 

The  patient  was  much  more  comfortable  as  the  result  of  an  ab- 
dominal support  which  held  up  the  enlarged  spleen. 

Under  .v-ray  treatment  she  seemed  to  be  getting  steadily  better 
until  the  ninth  of  No\ember,  when  she  had  a  slight  pain  in  the  left  back, 
wliich  later  in  the  evening  became  severe;  morphin,  |  grain  by  mouth, 
was  vomited. 

Respiration  was  slightly  quickened.  At  2  o'clock  in  the  morning 
of  November  loth  the  i)atient  had  a  chill  and  vomited.  The  pulse 
rose  to  130;  res])iration  was  very  rapid;  temperature,  99.4°  F.  ^Morphin, 
I  grain  subcutaneously,  gave  some  relief;    but  at  4.50  the  respiration 


lig.   14- 


-Showing  results  of  iicrcussion  and  jmlpation  in  a  ])ati('nt  c()mi)lainin<j;  only  of 
weakness  and  alidoniinal  eiilaruement. 


WEAKNESS  557 

suddenly  ceased.  No  cause  for  this  sudden  death  was  found  either 
before  or  after  the  autopsy,  which  showed  the  lesions  of  myelogenous 
leukemia. 

Diagnosis. — Myeloid  leukemia. 

Case  292 

A  married  woman  of  forty-four  was  first  seen  on  July  lo,  1907. 
Her  family  history  is  entirely  uneventful.  She  was  said  to  have  had 
cerebrospinal  meningitis  when  a  child,  and  has  ever  since  been  subject 
to  headaches  and  nose-bleeds.  The  menopause  occurred  five  years  ago. 
She  has  had  no  children  and  no  miscarriages. 

She  takes  two  glasses  of  beer  a  day,  but  never  takes  whisky.  She 
drinks  the  Boston  city  water  through  a  lead  pipe. 

Two  weeks  ago  she  became  so  weak  that  she  fell  to  the  floor,  striking 
the  back  of  her  head.  She  was  unconscious  for  about  an  hour,  and 
woke  up  in  bed,  where  she  had  been  put  by  her  husband.  Since  then 
she  has  been  unable  to  stand  unless  supported,  although  she  can  move 
her  legs  readily  in  bed. 

During  the  past  four  days  her  arms  and  fingers  have  become  numb 
and  Hfeless.  She  can  hold  a  knife  and  fork,  but  she  cannot  lift  a  glass 
of  water.  Her  speech  has  not  been  affected,  and  sphincteric  control 
is  perfect.  She  has  no  headache  and  sleeps  well.  The  bowels  are 
constipated;   her  appetite  is  poor. 

On  examination  the  patient  shows  loss  of  weight;  the  arteries  are 
palpable  and  tortuous  above  the  elbow;  the  heart,  lungs,  and  abdomen 
are  negative,  except  for  a  sharp  edge  felt  underneath  the  right  ribs. 
The  knee-jerks  are  not  obtained.  There  is  general  tenderness  over 
the  nerve-trunks  of  the  legs.  The  grip  of  both  hands  is  weak,  and  the 
extensors  of  the  wrist  are  likewise  weak. 

There  is  no  lead  line.  The  blood  shows  no  stippling.  The  urine 
is  normal  and  contains  no  arsenic. 

Discussion. — Evidently  this  is  a  different  type  of  weakness  from 
that  of  the  cases  we  ha\'e  been  ])reviously  studying.  It  is  referred 
more  'definitely  to  legs,  and  a])pears  suddenly.  Especially  when  we 
take  account  of  the  condition  of  the  nervous  system,  as  re\caled  bv 
physical  examination,  we  are  clear  that  the  case  does  not  belong  with 
those  in  which  weakness  is  due  to  cardiac  or  toxemic  conditions. 

The  ])ossible  connection  of  lead  with  the  trouble  is  naturallv  our 
first  thought,  since  the  history  mentions  a  lead  pipe.  It  must  be  remem- 
bered, howcNcr,  that  in  the  \ast  majority  of  cases,  water  eoniing  through 
lead  ])ipe  between  the  street  main  and  the  facet  within  the  house  does 


558  DIFFERENTIAL   DIAGNOSIS 

not  become  impregnated  with  lead  and  does  no  harm  to  any  one.    More 
over,  in  this  patient  the  tissues  most  sensitive  to  lead  and  most  apt  to 
show  its  influence  as  soon  as  poisoning  begins,  are  here  evidently  un- 
touched.    There  are  no  changes  in  the  gums  or  in  the  blood,  no  coUc, 
no  arthritis,  no  encephalopathy. 

Arsenical  poisoning  has  now  gone  out  of  fashion,  partly,  I  believe, 
because  the  neurologists  have  grown  tired  of  it  and  are  fonder  of  the 
term  ''neurasthenia"'  or  ''psychoneurosis,"  partly  because  our  wall- 
papers are  now  freer  from  arsenical  dyes.  The  absence  of  arsenic 
from  the  urine  in  the  present  case  would  probably  be  accepted  as  con- 
clusive evidence  against  the  presence  of  arsenical  poisoning.  On  the 
other  hand,  it  must  be  remembered  that  a  considerable  proportion  of 
the  community  often  passes  arsenical  urine  from  time  to  time  while  in 
perfect  health,  so  that  the  demonstration  of  the  mineral  is  by  no  means 
proof  of  arsenical  poisoning.  Negative  evidence  is  here  better  than 
positive. 

Epidemic  poliomyelitis  is  apt  to  occur  in  the  hot  summer  months, 
in  one  of  which  this  patient  was  attacked.  It  is,  however,  very  rare 
at  her  age,  does  not  often  attack  both  legs  or  produce  such  incomplete 
paralysis  of  the  muscles  involved.  Tenderness  over  the  nerve-trunks 
is  not  common. 

The  tenderness  just  referred  to  enables  us  to  rule  out  other  types  of 
myelitis  which  would  in  any  case  be  unlikely  to  produce  so  mild  a 
disturbance  of  motion,  without  increase  of  reflexes  or  involvement  of 
the  sphincters.  Alcoholic  neuritis  would  produce  practically  all  the 
symptoms  here  complained  of,  but  the  amount  of  alcohol  which  she 
admits  ha\'ing  consumed  seems  insufficient  to  ]:)roduce  so  severe  a  trouble. 
If  no  other  cause  can  be  discovered,  however,  we  may  have  to  disbelieve 
her  story. 

Beyond  any  reasonable  doubt  she  has  a  multiple  neuritis;  as  she  has 
had  no  fever,  we  cannot  call  it  an  infectious  type  of  neuritis,  and  all 
other  varieties,  except  that  referred  to  in  the  last  paragraph,  appear 
to  have  been  excluded.  On  the  whole,  alcoholic  neuritis  seems  the 
most  reasonaljle  diagnosis. 

Outcome. — Upon  cross-questioning  the  j)atient  later  admitted  that 
she  had  been  taking  four  bottles  of  ale  daily  for  a  number  of  months. 
As  a  result  of  continued  abstinence,  with  good  hygiene,  she  recovered 
entirely  in  the  course  of  three  months. 

Diagnosis. — Alcoholic  neuritis. 


WEAKNESS  559 


Case  293 


A  freight-handler  of  twenty-six  entered  the  hospital  August  14,  1907. 
He  had  always  been  previously  well  except  for  an  attack  of  fever  five 
years  ago.  He  began  to  lose  his  appetite  and  his  strength  two  weeks 
ago.     A  week  ago  he  was  so  weak  that  he  gave  up  work. 

In  the  last  ten  days  he  has  vomited  almost  everj'thing  he  has  eaten 
and  has  had  very  little  appetite.  He  has  also  had  a  cold  in  his  head, 
with  a  little  cough  and  pain  in  the  right  side  of  the  chest.  His  bowels 
are  regular,  but  he  sleeps  poorly. 

Physical  examination  shows  good  nutrition;  the  heart's  apex  is  in 
the  fifth  space  in  the  nipple-line,  but  the  heart-sounds  are  also  distinctly 
heard  to  the  right  of  the  sternum. 

There  is  dulness  at  the  base  of  the  right  lung  below  the  angle  of  the 
scapula,  accompanied  by  diminished  vocal  and  tactile  fremitus,  dimin- 
ished breath-sounds,  and  crackling  rales. 

Physical  examination,  including  the  blood  and  urine,  is  otherwise 
negative. 

Discussion. — Without  the  physical  examination  we  have  no  clue. 
Even  with  it  there  seems  to  be  but  little  to  account  for  so  much  prostra- 
tion, for  it  will  be  noted  that  the  breath-sounds  are  audible,  though 
diminished  over  the  whole  of  the  affected  side.  We  must  be  dealing 
either  with  a  very  small  accumulation  of  fluid  or  with  a  plastic  pleurisy 
resulting  in  thickening.  Is  this  enough  to  explain  so  much  weakness 
and  fever? 

Yes,  it  certainly  is  enough,  as  experience  has  repeatedly  shown  us, 
because  it  implies  with  reasonaUe  certainty  other  tul^erculous  lesions 
in  the  lung  itself,  in  the  internal  lym])hatic  glands,  or  elsewhere.  \'ery 
probably  that  attiick  of  fe\er  fne  years  pre\iously  was  also  due  to  tuber- 
culosis, possibly  also  pleural  in  situation,  though  nothing  of  the  kind 
was  recognized  at  that  time. 

Of  course,  we  must  run  o\er  in  our  minds  and  exclude  by  our  ques- 
tions or  ])hysical  tests  the  other  familiar  causes  of  weakness,  such  as 
anemia, .  ])S}choneurotic  conditions,  dialjctes,  concealed  se])sis,  and 
other  infections.  But  this  I  think  we  can  do  with  tlie  aid  of  the  data 
here  presented.  Doul)tless  we  are  right  in  ])eing  influenced  to  faxor 
the  diagnosis  of  tifl)erculosis  in  this  case  1)y  our  knowledge  that  many 
other  cases  demonstrated  Ijy  the  lapse  of  time  to  be  tul)erculous  ha\e 
begun  just  in  this  way. 

Outcome. — On  the  thirty-flrst  a  needle  was  inserted  in  tlie  bark.  'I 
inch    below    the   angle   of   the   sca])ula.     The   needle    ] visaed    through 


56o 


DIFFERENTIAL  DIAGNOSIS 


fully  i^  inches  of  thick,  gritty,  pleural  exudate  before  any  fluid  was 
obtained,  and  only  ^  ounce  came  out. 

The  course  of  the  temperature  is  seen  in  the  accompanying  chart 
(Fig.  143)- 


■Sa,f     /^  'S  't  ri  li  /jL«  11  Tt  ti,tJ,  u  il.  IJ^  A  }^Jt  n  ±    r-    ' 

J—"-..        /-  II  \,  III  -III  jil  II  II  11/  !!L  III  /I-  II'  //  /f  /^'/i'  1 '"  III 

\m-  *1"  —  ^S^  —  —  """""""  —  ""  —  — '- 

100 

100 

•     104 

.-    *"• 

u     '" 

B     W-  -A-i-^                                                                                  ^  -« 

"  '^ttt'^'lt%,~^Z^'tiit^Zt*^-^-'^-f-t 

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'"                                       1 

m                              "^^^^ 

-  IT.                  3    ^"                 ^         k 

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Fig.  143. — Chart  of  case  293. 

The  patient  rapidly  improved,  and  was  discharged  on  the  second  of 
September. 

Diagnosis. — Chronic  plastic  pleurisy. 


Case  294 

A  shipper  of  thirty-eight  was  first  seen  April  9,  1908.  He  has  been 
in  the  habit  of  taking  20  glasses  of  beer  a  day,  but  his  past  history,  as 
well  as  his  family  history,  is  otherwise  negative.  He  has  had  pneu- 
monia three  times,  the  last  time  four  years  ago.  A  week  ago  he  had 
the  grip,  from  which  he  is  now  convalescing.  He  now  feels  pretty  well, 
but  weak. 

Five  days  ago  some  albumin  was  found  in  his  urine  and  he  was 
put  upon  a  milk  diet.  Lately  he  has  vomited  his  milk.  There  has  been 
no  swelling  of  the  legs  or  face.  A  year  ago  he  weighed  190  pounds, 
now  he  weighs  170.  He  has  had  a  good  deal  of  cough  and  sputa  during 
the  past  week,  but  he  thinks  not  previously. 

On  physical  examination  he  was  found  to  be  rather  stout.     The 


Fig.  144. — Represents  what  was  found  to  explain  weakness  following  an  attack  called 
"grip."     (See  also  Fig.  145.) 


Fig.  145. — Signs  found  in  the  hack  (Case  2{)4)  of  a  ]>atient  com]ilaining  of  weakness  after 
an  attack  of  "grip."      (See  Fig.   144.) 


WEAKNESS 


S6i 


heart  is  negative.  The  condition  of  the  lungs  is  shown  in  the  accom- 
panying diagrams  (Figs.  144,  145). 

The  abdomen  was  held  firmly,  and  showed  some  dulness  in  the 
flanks,  which,  however,  did  not  shift  with  change  of  position. 

The  leukocytes  were  15,600;  hemoglobin,  85  per  cent.;  temper- 
ature, 97.4°  F.;  pulse,  96;  respiration,  24;  blood-pressure,  125  mm.  Hg. 
Urine  negative. 

The  liver  dulness  extended  from  the  sixth  rib  to  the  costal  margin. 
The  edge  of  the  organ  was  palpable.  The  sputa  showed  large  numbers 
of  pneumococci;  no  tubercle  bacilH  on  repeated  examination.  The 
ocular  tuberculin  reaction  was  negative. 

Discussion. — This  man  is  said  to  have  had  the  "grip."  Can  his 
weakness  be  accounted  for  merely  as  a  result  of  that  disease?  In  the 
epidemic  of  influenza  occurring  in  1889  and  1890  the  convalescence 
was  notoriously  slow  and  painful,  but  \\ithin  the  past  few  years  I  do 
not  believe  that  we  have  had  any  cases  of  that  type,  so  that  I  should 
doubt  \-cry  much,  even  before  scrutinizing  the  results  of  physical  ex- 
amination, any  explanation  of  this  patient's  weakness  as  the  result  of 
such  a  type  of  influenza  as  could  have  been  acquired  in  1908. 

Such  an  albuminuria  as  is  recorded  above  is  quite  often  seen  after 
mild  attacks  of  tonsillitis  or  nasopharyngitis — i.  e.,  a  common  cold. 
The  urinary  findings,  therefore,  do  not  imply  that  the  previous  infec- 
tion has  been  anything  more  serious  than  a  cold.  But  the  physical 
signs  in  the  lungs  certainly  do  imply  something  more,  and  can  be  ex- 
plained only  as  the  result  of  some  type  of  ])neumonia  or  as  the  results  of 
tuberculosis. 

Delayed  resolution  in  jmeumonia  is  so  rare  that  one  should  never 
make  the  diagnosis  with  confidence  unless  em])yema,  especially  in  the 
interlobar  form,  ])ulmonary  aljsccss,  and  tuberculosis  can  be  excluded. 
The  negative  tuberculin  reaction  is  here  of  very  c()nsideral)le  value. 
The  negative  results  of  sputum  examination  arc  also  of  some  importance, 
especially  as  their  num])er  is  considerable. 

These  two  facts,  together  with  the  a])sencc  of  fe\"cr  and  the  presence 
of  a  transient  albuminuria,  should  incline  us  to  decide  against  tul)er- 
culosis,  and  in  fa\'or  of  some  acute  infection  of  the  luiigs,  now  prol);il)ly 
in  the  stage  of  convalescence. 

Outcome. — A])ril  ryth  tlie  signs  in  the  lungs  were  mucli  less  niarkid. 
April  28th  examination  showed  nothing  abnonnai,  and  the  ])atuMU  felt 
quite  well. 

Diagnosis. — Convalescence  from  ])neumonia. 


562 


DIFFERENTIAL   DIAGNOSIS 


Case  295 

A  Jewish  peddler  of  seventeen,  never  previously  sick,  entered  the 
hospital  July  6,  1907. 

He  was  in  bed  four  months  ago  for  a  few  days  on  account  of  a  sUght 
cough  and  expectoration,  which  was  never  bloody.  After  a  week  he 
returned  to  work,  but  then  he  had  pain  in  his  legs,  relieved  by  flat-foot 
plates.  He  still  felt  very  weak  and  run  down,  and  through  the  aid  of 
the  Social  Service  Department  was  sent  to  a  farm,  whence  he  returned 
after  two  weeks  unimproved;  indeed,  since  his  return  has  been  getting 

weaker.     He  is  very  easily  tired  and  short 
of  breath  on  exertion. 

He  says  he  has  pains  all  over,  a  very 
poor  appetite,  cannot  sleep,  and  is  feverish 
and  chilly  at  times.     (See  Fig.  146.) 

The  patient  was  found  to  be  poorly 
nourished.  Physical  examination  was 
otherwise  entirely  negative,  save  for  sharp 
lateral  curvature  of  the  spine  to  the  right 
in  the  midscapular  region.  Tuberculin 
(o.i,  I,  5,  and  10  miUigrams)  was  injected 
subcutaneously,  but  was  not  followed  by 
any  rise  of  temperature  or  any  constitu- 
tional symptoms.  The  blood  and  urine 
were  entirely  normal.  In^•estigation  of 
the  gastric  functions  with  a  stomach-tube 
showed  no  fasting  contents,  a  capacity  of 
40  ounces,  and  after  a  test-meal:  free 
HCl,  0.18;  total  acidity,  0.44. 
Discussion. — The  onset  of  this  illness  is  very  characteristic  of 
tuberculosis.  Cough,  fever,  anorexia,  weakness,  shortness  of  breath, 
chilliness,  insomnia — all  ]3oint  in  that  direction.  It  will  need  the  strong- 
est kind  of  e\idence  to  convince  us  that  this  boy  is  free  from  the  tuber- 
culous taint. 

By  continued  obser\'ation,  however,  by  repeated  examinations  of 
the  lungs,  and  especially  by  the  negative  results  of  tuberculin  injections, 
it  was  possible,  in  my  judgment,  to  exclude  tuberculosis. 

The  gastric  functions  were  then  carefully  studied,  but  nothing  of 
any  importance  as  evidence  of  disease  was  discovered.  By  the  study 
of  the  blood  and  urine  we  were  able  further  to  narrow  the  field  of 
possibilities.       No    evidence    of    syphilis    or   other   infectious    disease 


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Fig.  i46.^C"harl  of  case  295. 


WEAKNESS  563 

could  be  found.  The  eyes  and  ears  were  examined,  with  negative 
results. 

After  all  these  tests  had  turned  out  negative,  it  seemed  justifiable 
to  return  to  that  most  obvious  and  yet  most  perilous  diagnosis,  a  func- 
tional nervous  derangement.  The  age  of  the  patient  and  his  race 
doubtless  helped  to  justify  such  a  diagnosis.  The  more  one  sees  of 
adolescence,  the  more  one  is  astonished  at  the  apparent  gravity  but 
eventual  transiency  of  the  physical  and  mental  symptoms  exhibited 
by  some  healthy  people  at  that  period.  Boys  and  girls  who  turn  out 
quite  healthy,  sensible,  and  reliable  in  adult  life,  may  be  almost  incon- 
ceivably weak,  vacillating,  hypochondriacal,  and  turbulent  at  that 
period.  All  their  vital  forces  seem  to  be  slowing  down  or  hobbling 
along  as  if  about  to  stop  altogether.  This  applies  to  all  races,  but  more 
especially  to  the  Jews. 

Outcome. — By  the  twelfth  of  July  he  was  eating  better  and  behanng 
as  if  he  had  some  strength.  He  had  received  up  to  that  time  no  drugs 
except  an  occasional  dose  of  veronal,  10  grains,  for  insomnia.  His 
blood-pressure  on  the  twenty-second  was  115  mm.  Hg.  At  this  time 
he  looked  and  felt  much  better,  but  did  not  gain  in  weight.  Potassium 
iodid  was  tried  in  large  doses,  but  produced  no  impro\cmcnt. 

After  eight  weeks  of  observation,  with  careful  study  of  the  case,  we 
were  convinced  that  the  patient's  mental  attitude  had  a  great  deal  to  do 
with  his  condition.  After  some  reeducation  he  was  discharged  much 
relieved. 

Diagnosis. — Psychoneurosis. 

Case  296 

A  married  woman  of  forty-three,  of  good  family  history,  entered  the 
hospital  May  22,  1908.  She  had  "inllammation  of  the  bowels"  twelve 
years  ago  and  was  sick  for  two  months.  Before  and  since  that  time 
she  has  been  well  until  two  weeks  ago,  when  she  began  to  feel  tired  and 
weak  all  over.  She  has  had  no  pain  anywhere,  but  her  a])])etite  has  been 
poor.  For  a  week  she  has  noticed  chilly  sensations,  with  a  scantv,  liigh- 
colored  urine.  Two  days  ago  she  had  a  sore  throat  and  took  to  her 
bed.  Now  the  sore  throat  has  disappeared.  She  has  not  Ix'cn  exposed 
to  ty])lK)id  fever,  so  far  as  she  knows.     She  has  no  cough. 

The  course  of  the  temperature  is  seen  in  the  accompanying  chart 
(Fig.  147).  A  systolic  murmur  is  heard  all  over  the  heart's  area,  loudest 
in  the  pulmonary  area.  The  aortic  second  is  louder  than  the  pulmonic 
second  sound.  'Hie  heart's  apex  is  in  the  midchnicular  line.  ]'.  inches 
to  the  left  of  midsternum. 


564 


DIFFERENTIAL   DIAGNOSIS 


The  arteries  and  lungs  show  nothing  abnormal.  There  is  some 
dulness  in  the  flanks,  but  this  does  not  shift  with  change  of  position. 
The  abdomen  is  otherwise  negative.  Blood  cultures  and  Widal  reac- 
tion were  persistently  negative.  The  white  cells  at  entrance  were  10,700, 
the  urine  normal.  The  urine  was  25  to  30  ounces  in  twenty-four  hours, 
specific  gravity  loio,  no  albumin,  no  casts  or  cells. 

Menstruation  came  on  about  the  time  she  was  first  seen,  and  was 
profuse,  but  not  abnormal. 

Discussion. — It  is  safe  to  assume  that  the  fever  and  the  weakness 
should  be  grouped  together  as  the  result  of  a  common  cause. 

Though  there  is  a  systolic  murmur  over  the 
precordia,  it  is  not  so  situated  or  so  supported 
by  other  physical  signs  as  to  be  in  itself  satis- 
factory evidence  of  endocarditis  or  of  any  other 
cardiac  lesion. 

Tuberculous  peritonitis  would  account  for 
many  of  the  symptoms,  but  we  have  no  physical 
signs  sufficient  to  justify  any  such  hypothesis. 
In  an  abdomen  which  is  otherwise  negative, 
dulness  in  the  flanks  means  nothing  of  import- 
ance unless  it  shifts  with  change  of  position. 

We  tried  our  best  to  make  this  case  fit  the 
diagnosis  of  typhoid  fever,  but  could  never  ob- 
tain any  positive  evidence  of  it. 

Urinary  infection  seemed  very  improbable, 
as  the  sediment  of  the  urine  showed  nothing 
pathologic.  Xo  culture,  howe^■er,  was  made  from 
it,  and  if  another  cause  for  fever  and  weakness 
had  not  been  discovered,  bacteriologic  investiga- 
tion of  the  urine  would  ha\'e  been  in  order. 
The  reader  will,  I  ho])e,  have  noted  that  one  method  of  physical 
examination,  essential  as  ])art  of  a  thorough  study  in  any  obscure  case, 
is  here  omitted.  Doubtless  it  was  this  mistake  which  postponed  our 
making  the  correct  diagnosis.  I  refer,  of  course,  to  the  pehic  examination. 
Outcome. — The  cause  of  the  weakness  and  fe\'er  remained  quite 
unexplained  until  May  30th,  when  the  leukocyte  count  was  discovered 
to  have  risen  to  30,000.  This  at  last  suggested  a  vaginal  examination, 
which  showed  that  the  uterus  \\'as  considerably  enlarged.  To  its  left  a 
mass,  the  size  of  an  orange,  a])parently  attached  to  the  fundus,  extended 
upward.  Another  rounded  mass  seemed  to  be  attached  to  the  anterior 
uterine  wall. 


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147. — Chart     of 
case  296. 


WEAKNESS 


565 


An  uncomplicated  fibroid  tumor  would  not  have  produced  so  much 
weakness  and  fever.  Were  it  strangulated,  degenerated,  suppurating, 
or  in  process  of  producing  a  localized  peritonitis,  there  should  have  been 
pain.  Fibroid  must,  therefore,  be  ruled  out  or  recognized  as  a  subor- 
dinate part  of  the  diagnosis.  Cyst  of  the  ovary  or  the  broad  ligament 
should  produce  more  acute  symptoms  if  its  pedicle  were  twisted,  and  less 
fever  if  it  were  in  a  normal  condition. 

In  view  of  these  considerations,  pelvic  suppuration,  probably  de- 
pendent upon  a  pus-tube,  seems  the  most  probal^le  diagnosis. 

Operation  June  2d  revealed  a  large  pelvic  aljscess  to  the  left  of  the 
uterus  and  a  pus-tube  on  the  right.  There  were  also  two  small  fibroid 
tumors  attached  to  the  fundus  uteri.  These  were  shelled  out,  the  pus 
was  drained,  and  the  patient  made  a  good  recovery. 

Diagnosis. — Pus-tube. 

Case  297 

An  Italian  laborer  of  forty-eight,  of  good  family  history  and  past 
history,  was  first  seen  October  11,  1907.  He  had  a  nose-bleed  ten  days 
ago,  and  has  since  then  suffered  from  general  malaise  and  weakness, 
with  moderate  headache,  ill-defined  ab- 
dominal ])ain,  and  slight  cough. 

Physical  examination  showed  a  swarthy, 
well-developed  man,  breathing  rapidly  but 
easily.  (See  accompanying  chart,  Fig.  148.) 
He  wa.s  almost  without  complaint  when  seen, 
though  his  face  was  flushed,  his  breath  very 
offensi\e.  The  cardioN'ascular  system  was 
negative.  Breathing  throughout  the  right 
back  seemed  more  feel)le  than  in  the  left, 
otherwise  the  lungs  were  entirely  negative, 
as  was  the  al)domen. 

The  white  cells  were  7000;  hemoglobin, 
85  per  cent. ;  Widul  reaction,  negative;  tlic 
urine  a\"craged  50  ounces  in  twenty- four 
hours;  sj)ccific  gravity,  1013;  there  was  tlic 
slightest  ])()ssil)le  trace  of  al])umin;  very 
many  hyaline  and  granular  casts,  some  with 
cells,  and  a  small  amount  of  fat  adherent. 

On  the  succeeding  day  the  patient  coughed  u])  some  strijigy  \ellow 
sputa  contiiining  many  cocci  and  bacilli,  but  nothing  distincli\e. 


Fig.  14S. — Chart  (.f  ca:- 


c66  DIFFERENTIAL   DIAGNOSIS 

An  expert  examination  of  the  upper  air-passages  showed  the  foul 
breath  to  be  due  to  atrophic  rhinitis. 

On  the  fifteenth  the  patient  began  to  raise  mouthfuls  of  thick,  reddish- 
gray,  odorless  pus,  looking  like  that  from  gangrene  of  the  lung,  but 
without  the  characteristic  odors.  It  contained  a  variety  of  organisms, 
but  no  tubercle  bacilli.  On  the  seventeenth  the  lungs  were  so  full  of 
coarse,  bubbling  rales  that  the  heart-sounds  were  inaudible. 

The  right  axilla  was  duller  than  the  left. 

On  the  eighteenth  the  abdomen  began  to  be  distended,  the  neck  to 
be  slightly  stiff.  The  face  expressed  extreme  anxiety  and  dread.  On 
the  eighteenth  the  sputum  began  to  have  a  foul  odor,  and  the  right  thigh 
became  generally  tender  on  motion  and  somewhat  swollen. 

On  the  nineteenth  the  white  cells  had  risen  to  14,900.  On  the 
twentieth  an  abscess  appeared  on  the  top  of  the  left  shoulder,  and  a 
similar  one,  painful,  indurated,  and  red,  appeared  in  the  right  groin 
below  Poupart's  ligament. 

The  patient  lost  strength  rapidly;  cyanosis  and  a  foul,  frequent 
diarrhea  developed. 

Discussion. — This  case  begins  just  hke  a  typhoid,  and  at  first  there 
seemed  to  be  nothing  else  that  we  could  call  it,  although  there  was  no 
Widal  reaction,  no  rose  spots  or  splenic  enlargement,  no  bacilli  by 
blood  culture,  and  nothing  characteristic  about  the  temperature-curve. 
But  as  we  could  find  no  signs  of  tuberculosis,  septicemia,  synhilis,  or 
any  other  type  of  obscure  fever,  our  best  guess  was  typhoid  during  the 
first  four  days  of  the  illness. 

When  the  pus  began  to  come  up  and  was  found  to  be  free  from 
tubercle  bacilli,  we  began  to  search  for  further  cN'idence  of  pulmonary 
abscess.  Nothing  localizing  could  be  found,  but  this,  as  experience  has 
shown,  is  often  the  case  in  abscess  of  the  lung.  Our  present  methods  of 
physical  examination — even  when  supplemented  by  radiography — 
are  not  sufficiently  accurate  to  reveal  the  presence  of  pulmonar}-  abscess 
in  all  cases.  We  may  have  a  little  patch  of  dulness  and  diminished 
breathing,  or  rales  may  be  heard  over  a  circumscribed  area;  but  nothing 
characteristic  is  often  found,  cspeciallv  when  the  abscess  is  multiple 
and  small.  It  is  quite  possible  that  the  pus  came  entirely  from  the 
bronchi  in  this  case. 

When  the  peripheral  abscesses  began  to  appear,  our  attention  was 
no  longer  concentrated  on  the  lungs,  and  it  began  to  be  clear  that  we 
were  dealing  with  a  general  mfection.  When  the  pericarditis  de\'eloped, 
there  was  no  Ioniser  any  reasonal)le  douljt  of  the  diagnosis. 

Outcome. — Blood   cultures  made   on   the  twenty-first  of   Octol:)er 


WEAKNESS 


567 


showed  the  staphylococcus  aureus  without  any  admixture  of  other 
organisms.  The  same  coccus  w^as  obtained  from  the  external  abscesses. 
On  the  twenty-fourth  the  patient  died,  no  benefit  having  been  obtained 
from  an  autogenous  vaccine. 

Diagnosis. — Staphylococcus  sepsis. 

Case  298 

An  unmarried  stenographer  of  twenty-nine  had  lost  her  mother  of 
typhoid  fever  and  one  sister  of  acute  tuberculosis  two  and  one-half  years 
ago.     She  was  first  seen  by  me  March  12,  1908. 

The  patient  had  bronchitis  for  a 
whole  year  when  twelve  years  old,  but 
has  since  been  well  until  the  previous 
fall,  when  she  became  run  down,  lost 
appetite,  and  had  some  pain  in  the  left 
upper  chest.  Her  chief  complaint  at 
this  time  was  of  weakness.  She  went 
to  the  country  and  remained  there  two 
months,  with  some  impro\ement,  so 
that  she  was  able  to  go  to  work  again 
on  Januar)'  13,  1908;  but  as  soon  as 
she  took  up  her  work  again  she  began 
to  lose  appetite,  and  felt  very  tired  and 
often  chilly  at  night  after  her  work. 
She  had  no  cough  and  no  pain,  and 
continued  to  work  until  two  days  ago, 
when  she  noticed  fever  and  headache 
and  began  to  cough  and  raise  yellow 
sputa. 

Yesterday  evening  her  temperature  was  said  to  ha\e  been  104°  F. 
For  the  last  two  days  slie  has  had  no  sputa.  She  has  now  no  pain  any- 
where. (For  the  course  of  the  temperature  see  the  accompan}ing  chart. 
Fig.  149.) 

The  patient  is  well-nourished,  ruddy;  the  heart  and  vessels  show 
nothing  aljnormal.  0\cr  the  right  clavicle  in  front,  and  abo^e  the  s])ine 
of  tlic  sca])ula  behind,  there  is  slight  dulness,  increased  whisper,  in- 
creased vocal  and  tactile  fremitus,  broncliovesicular  breathing,  and  a 
few  fine  crackling  rales.  Kernig's  isthmus  and  the  excursion  of  the  lung 
are  equal  on  tlie  two  sides. 

Physical  examination,  including  the  l)loo(l  and  urine,  is  otherwise 
negative. 


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568  DIFFERENTIAL  DIAGNOSIS 

Discussion. — Many  patients  of  this  type  have  to  suffer  by  reason 
of  a  mistaken  diagnosis  of  general  debility,  neurasthenia,  or  "grip." 

The  latter  diagnosis  is  difficult  positively  to  exclude.  A  few  cases 
are  on  record  which  prove  that  an  influenzal  bronchopneumonia  may 
be  so  localized  at  the  apex  of  a  lung  as  to  simulate  tuberculosis.  Such 
cases,  however,  are  very  rare,  and  for  practical  purposes  may  be  dis- 
regarded. 

The  physical  signs  of  this  case,  though  strongly  suggestive  of  tuber- 
culosis, are  not  in  themselves,  and  in  the  absence  of  any  longer  pyrexia, 
conclusive.  The  so-called  bronchitis,  which  lasted  a  whole  year  during 
the  patient's  childhood,  doubtless  inclines  us  to  interpret  any  dubious 
pulmonary  signs  as  e\idence  of  tuberculosis.  But  it  must  be  remembered 
that  such  signs  may  be  the  harmless  residual  effects  of  an  old  burnt-out 
process  which  do  not  necessarily  signify  anything  of  importance  at  the 
present  time.  One  of  the  most  difficult  tasks  that  I  know  of  in  connec- 
tion with  pulmonary  diagnosis  is  to  distinguish,  by  physical  signs  alone, 
the  scars  of  an  old  healed  process  from  the  e\idences  of  a  new  and  threat- 
ening one.  In  many  cases  the  differentiation  of  the  two  is  impossible 
until  the  progress  of  the  symptoms  supplements  our  physical  examination. 

Despite  several  negative  examinations  of  the  sputa,  our  pro\isional 
diagnosis  was  phthisis,  the  most  decisive  point  in  our  minds  being  the 
sharp,  crackling  quality  of  the  rales,  although  they  were  elicited  only 
by  cough. 

Outcome. — After  repeated  negative  examinations  of  the  sputa, 
tubercle  bacilli  were  finally  found  March  19th.  On  the  twenty-seventh 
she  went  to  a  sanatorium  for  the  tuberculous. 

Diagnosis. — Phthisis. 

Case  299 

A  housemaid  of  twenty-four  entered  the  hospital  July  15,  1908. 
Her  family  history  and  past  history  are  good.  She  has  one  child  eight 
months  old.  Ever  since  this  baby  was  bom  she  has  complained  of 
weakness.  Though  the  labor  was  normal  and  not  difficult,  she  has 
been  able  to  walk  since  the  baby  was  born  but  a  few  steps,  owing  to 
muscular  weakness  and  edema  of  the  legs.  These  troubles  have  been 
notable  for  t\\o  months,  and  have  been  accompanied  by  dyspnea  on 
exertion.  Pallor  has  also  been  noticed  ever  since  the  baby  was  bom. 
For  the  past  month  she  has  also  had  some  pain  in  the  chest  on  taking  a 
deep  breath.  She  has  no  other  ])ain.  Her  appetite  is  good,  her  bowels 
are  regular,  her  sleep  is  fair.  The  course  of  the  temperature  is  seen  in 
the  accompanying  chart  (Fig.  150). 


WEAKNESS 


569 


The  patient  is  emaciated,  pale,  has  one  large  submental  gland,  and 
several  small  postcervical  glands.  The  heart  shows  no  enlargement 
and  no  murmurs.  The  sounds  are  regular,  clear,  rapid.  The  blood- 
pressure  is  100  mm.  Hg.  The  lungs  are  negative  except  for  one  or  two 
squeaking  rales  above  the  right  clavicle  and  at  the  right  base  behind, 
with  slight  dulness,  and  diminished  breathing. 

In  the  abdomen  there  is  dulness  at  the  sides,  which,  however,  does 
not  shift  to  any  extent  with  change  of  position. 

There  is  a  right  lateral  curvature  of  the  spine,  projecting  somewhat 
backward,  and  involving  the  twelfth  dorsal  and  the  first,  second,  and 
third  lumbar  vertebrae.  A  pelvic  examination  is  negative.  Blood 
examination  shows  marked  achromia,  and  some 
variation  in  size  and  shape.  Urine  is  normal. 
Reflexes  normal. 

On  the  eighteenth  there  was  distinct  evidence 
of  fluid  in  the  abdomen,  and  the  signs  at  the 
apex  of  the  lung  were  no  less  evident. 

Discussion. — At  first  sight  the  cardiac 
symptoms  appear  to  be  in  the  foreground.  The 
edema,  the  dyspnea,  the  ascites,  and  the  low 
blood-pressure  all  point  in  this  direction,  but 
the  examination  of  the  licart  gives  no  support 
to  the  idea  that  any  type  of  heart  disease  is 
{)resent. 

There  is  a  good  deal  to  suggest  tul)ercu- 
losis,  especially  the  rather  equivocal  pulmonary 
signs  and  the  association  of  ascites  with  fever. 
On  the  other  hand,  if  the  belly  fluid  were  due  to 
tul)crculous  ])eritonitis,  we  should  expect  ])ain, 
tenderness,  or  spasm,  none  of  which  is  j)rescnt. 

From  the  blood  examination  it  a])pcars  that  the  patient  is  anemic, 
and  much  of  her  weakness  is  doubtless  due  to  this  cause,  but  the  details 
of  tlie  Ijlood  examination  are  such  as  to  compel  us  to  seek  some  further 
cause  for  the  anemia  itself. 

The  si)inal  deformil}-  might  l)e  either  the  result  of  some  old  quiescent 
tr()u])le  or  of  a  more  recent  disease.  Since  there  are  reasons  to  suspect 
tuberculosis  in  other  parts  of  the  Itody,  tlie  thought  of  Pott's  disease 
should  cross  our  minds.  This  leads  straight  to  an  .v-ra}'  examination 
as  the  next  ste])  in  the  study  of  the  case. 

Outcome. — A'-ray  of  the  sjiine  sliowed  telescoping  of  the  \ertebra\ 
It  was  suljsecpiently  learned  that  this  proniinenee  in  the  l)aek  had  existed 


•s^  U^  ,t, 

i**  j/j^  A  >i 

^^...4    /I//. 

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H 

Cm 

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. 

, 

4        -iJ-^ 

l':^'tt 

Ztl'^T'^ 

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J 

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z  di — 

.« 

no 

:  -ff-.: 

„           1        ' 

la         '      ' 

1           1 

.  j 

^-^^!#S 

"1  *&^ 

Fig.  150. 


-Chart  of  case 
299. 


570  DIFFERENTIAL   DIAGNOSIS 

for  three  years  and  had  been  accompanied  by  some  pain  in  the  back  at 
the  beginning  of  an  attack  of  "lumbago." 

The  patient  was  much  reheved  by  a  plaster  jacket. 

Diagnosis. — Vertebral  tuberculosis. 

Case  300 

A  carriage  painter  of  thirty-seven  entered  the  hospital  February 
20,  1908.  His  father  died  of  ulcer  of  the  stomach,  his  mother  of  pneu- 
monia, one  sister  and  one  cousin  of  pulmonary  tuberculosis.  The 
patient  has  always  been  perfectly  well.  He  denies  venereal  disease 
and  has  good  habits.  Two  years  ago  he  overworked,  and  has  since 
had  much  to  worry  him,  especially  his  wife's  sickness  (heart  disease) 
and  the  death  of  one  of  his  children.  Apparently,  as  a  result  of  these 
troubles,  he  has  been  gradually  running  down,  and  last  October  had 
to  quit  work  on  account  of  general  weakness  and  stomach  trouble.  He 
has  an  excellent  appetite,  but  frequently  vomits,  especially  in  the  morning 
before  breakfast.  His  bowels  are  loose,  moving  usually  two  or  three 
times  a  day.  For  three  months  he  has  been  short  of  breath  and  has  a 
little  cough  and  expectoration.  For  two  months  he  has  been  troubled  with 
numbness  in  his  hands  and  feet.  For  three  weeks  he  has  had  night-sweats. 
His  average  weight  is  135  pounds.     At  present  he  weighs  118  pounds. 

Physical  examination  showed  a  sallow,  somewhat  emaciated  young 
man  with  partial  right  wrist-drop;  the  chest  entirely  negative.  The 
abdomen  was  ver}'  rigid  throughout,  tympanitic,  but  not  tender.  The 
blood  was  examined  20  or  30  times  at  weekly  intervals.  At  entrance 
the  red  cells  were  1,062,000.  From  that  point  they  rose  by  Alarch  24th 
to  1,880,000,  after  which  they  gradually  declined,  reaching  570,000  on 
the  twenty-second  of  June.  The  white  cells  ranged  between  4000 
and  7000.  The  hemoglobin  at  entrance  was  55  per  cent.,  and  remained 
always  relatively  high. 

The  differential  count  showed  nothing  remarkable.  In  the  stained 
specimen  the  red  cells  showed  considerable  stippling,  some  achromia 
in  the  smaller  cells,  and  deep  staining  of  the  larger  ones.  Megaloblasts 
were  always  present  and  in  excess  of  the  normoblasts. 

The  urine  was  normal  throughout.  The  stools  were  not  remarkable. 
Parasites  were  repeatedly  searched  for.  but  never  found. 

The  skin  showed  a  l)rownish  pigmentation,  which  gradually  increased 
in  tint,  though  no  arsenic  was  given  during  his  stay  in  the  hospital. 

The  ocular  tuberculin  reaction  was  negative;  the  urine  and  stools 
contained  no  lead.  Throughout  his  stay  in  the  hospital  he  complained 
of  nothing  but  weakness  and  numbness  of  tlie  extremities. 


WEAKNESS 


571 


By  the  thirteenth  of  May  he  had  a  chill,  the  temperature  rising  to 
104.6°  F.  Previous  to  that  time  it  had  ranged  between  98°  and  icx)° 
F.  After  that  there  was  a  moderate  pyrexia — 99°  to  loi  °  F. — for  about 
one-half  of  the  rest  of  his  stay.     No  cause  for  the  chill  was  found. 

Discussion. — Carriage  painters  often  get  lead-poisoning.  Because 
of  this  patient's  occupation,  as  well  as  for  other  reasons  presently  to  be 
mentioned,  plumbism  is  the  first  possibility  which  calls  for  investiga- 
tion. Our  patient  has  a  wrist-drop,  various  troubles  with  his  stomach, 
and  stippling  of  the  red  blood-corpuscles,  all  of  which  signs  point  toward 
lead.  On  the  other  hand,  the  blood-picture  is  distinctly  that  of  primary 
anemia.  His  gums  show  no  lead  line  and  his  wrist-drop  turns  out  on 
inquiry  to  be  an  affair  of  very  long  standing.  The  degree  of  anemia, 
moreover,  aside  from  its  t}^pe,  is  greater  than  that  seen  in  any  but  the 
severest  cases  of  lead-poisoning,  such  as  exhibit  extensive  paralyses  and 
encephalopathy.  Finally,  the  absence  of  lead  in  the  stools  and  urine 
decisively  excludes  plumbism. 

The  brownish  pigmentation  of  the  skin,  steadily  increasing  at  a  time 
when  no  arsenic  was  given,  suggests  Addison's  disease  of  the  suprarenal 
capsules,  rather  than  the  anemia  first  described  by  him.  The  weakness 
and  stomach  trouble  are  quite  in  harmony  with  this  idea.  On  the  otiier 
hand,  suprarenal  disease  is  never,  so  far  as  I  am  aware,  associated  witli 
so  severe  an  anemia  except  in  the  acutest  and  most  fulminating  cases. 
In  the  great  majority  the  anemia  is  very  moderate.  The  negative  ocular 
tuberculin  reaction  helps  to  convince  us  that  we  are  not  dealing  with 
the  commonest  type  of  Addison's  disease — suprarenal  tuberculosis. 

Pernicious  anemia,  then,  seems  to  be  the  most  reasonable  diagnosis, 
although  the  patient  is  rather  younger  than  most  of  those  who  suffer 
from  this  t\'pe  of  anemia.  The  chill  and  sudden  rise  of  temperature 
on  the  thirteenth  of  May  puzzled  us  somewhat.  Fever,  it  is  true,  is  the 
rule  in  pernicious  anemia,  but  not  so  sudden  and  sharp  a  rise.  Probaljly 
it  is  to  be  explained  as  the  result  of  some  secondary  infection  fa^•orcd  b\- 
the  great  weakening  of  general  resistance.  I  haNe  seen  a  good  many 
similar  attiicks  in  the  last  few  years,  all  of  them  ])assing  off",  as  in  thi> 
case,  without  any  indication  of  their  source. 

Outcome. — The  edema  of  the  feet  and  the  general  weakness  in- 
creased steadily,  so  that  by  the  first  of  July  he  was  confined  to  bed. 
Death  occurred  July  igth. 

Aut()])sy  showed  the  usual  lesions  of  pernicious  anemia.  The 
suprarenal  ca])sulcs  were  normal. 

Diagnosis. — Pernicious  anemia. 


572  DIFFERENTIAL   DIAGNOSIS 


Case  301 


A  real-estate  agent  thirty-six  years  old  consulted  me  February  15, 
1909,  complaining  of  weakness  and  headache.  Although  he  has  an 
excellent  appetite  and  perfect  digestion,  he  has  lost  25  pounds  in  the 
last  two  years,  14  pounds  of  which  were  lost  within  the  last  three  months. 

His  family  history  is  good  except  that  his  father  died  of  tuberculosis. 

His  past  history  was  uneventful  until  September,  1901,  when  he  had 
tvphoid  fever.  In  1904  he  had  a  good  deal  of  pain  in  his  shoulders, 
which  passed  off,  however,  within  a  few  months,  though  no  diagnosis 
or  treatment  was  given.  For  the  next  three  years  he  was  quite  well, 
but  in  December,  1907,  he  had  pains  in  his  left  arm,  diagnosed  as  neu- 
ritis. By  reason  of  this  he  was  kept  out  of  work  in  January  and  February, 
1908,  and  in  August  and  September  of  the  same  year, 

November  7,  1908,  he  had  an  attack  of  vomiting,  accompanied  by 
severe  headache,  and  was  kept  in  bed  a  week.  Ever  since  that  time 
he  has  been  troubled  by  headache,  which  is  worse  on  waking  in  the 
morning,  and  usually  clears  off  at  noon.  It  afTects  especially  the  vertex 
and  the  frontal  region,  but  is  not  changed  in  any  way  by  the  position, 
by  diet,  or  by  the  weather.  His  eyes  have  been  examined  by  a  specialist 
and  i)ronounced  entirely  normal  except  for  a  horizontal  nystagmus  of 
almost  minute  excursion.  His  nose  has  also  been  carefully  examined, 
but  nothing  found. 

He  had  no  fever  at  any  time,  but  his  physician  tells  him  that  his 
pulse  is  rarely  below  100.  From  time  to  time  he  has  had  slight  jaundice. 
Since  November  7th  he  has  felt  unable  to  work,  and  since  December 
he  has  passed  urine  once  or  twice  every  night  after  bed-time. 

Physical  examination  shows  rather  poor  nutrition;  the  internal 
viscera  are  entirely  negative,  except  that  the  pulse  is  1 10 — not  an  unusual 
rate  during  an  office  consultation  in  patients  of  any  tendency  to  nervous- 
ness. The  knee-jerks  are  unusuallv  livelv;  the  blood-pressure,  155  mm. 
Hg. 

The  urine  is  of  normal  color;  40  ounces  in  twenty- four  hours; 
specific  gravity,  1023,  no  albumin,  no  sugar.  Several  subsequent  ex- 
aminations showed  essentially  the  same  conditions.     Blood  normal. 

Discussion. — Loss  of  weight  with  a  good  appetite  is  a  rather  rare 
combination  of  sym])toms.  Diabetes  is  its  only  quite  familiar  cause, 
and  that  disease  can  be  immediately  ruled  out  of  consideration  in  view 
of  the  urinary  findings. 

Aside  from  diabetes  I  have  met  with  this  combination  of  symptoms 
in  persons  who  are  losing  a  great  deal  of  slee])  by  reason  of  ])ain  or 


WEAKNESS  573 

emotional  strain,  in  certain  stages  of  arteriosclerosis,  and  in  hyper- 
thyroidism. This  patient's  headaches  never  prevented  his  sleeping. 
He  had  no  special  causes  for  anxiety,  and  seemed  to  be  in  good  spirits: 
There  was  no  good  reason  to  suspect  arteriosclerosis,  and  no  external 
evidence  of  that  disease. 

Hyperthyroidism  (Graves'  disease)  should  always  be  suspected 
when  a  patient  loses  weight  despite  a  good  appetite,  especially  if  there 
is  any  tendency,  as  in  this  case,  toward  tachycardia.  As  I  examined 
this  patient  with  special  reference  to  hy]jerthyroidism,  I  found  no  trace 
of  goiter  or  exophthalmos,  but  quite  a  definite  fine  tremor  of  the  fingers 
when  extended. 

Outcome. — Under  a  regime  of  overfeeding  and  rest  the  patient's 
headaches  became  much  less  frequent,  his  pulse  slower,  and  his  weight 
increased.     In  October,  1909,  he  was  back  at  work. 

Diagnosis. — Hyperthyroidism  (Graves'  disease). 

Case  302 

I  was  consulted,  September  4,  1906,  by  a  widow  aged  sixty-four, 
whose  chief  and  most  distressing  complaint  was  weakness.  Her  weight 
had  shown  no  change;  her  appetite  was,  she  said,  "too  good,"  and  her 
sleep  excellent.  She  had  no  ])ain,  cough,  or  vomiting,  but  she  had 
been  losing  strength  steadily  for  years,  and  for  the  past  tweh'e  months 
had  been  decidedly  short  of  breath.  In  1891  she  had  been  treated  by 
Dr.  Arthur  T.  Cabot  for  hemorrhoids,  wliich  never  bled  at  all,  as  far 
as  she  knew,  until  two  years  ago,  when  there  began  to  be  some  bleeding 
each  month  for  a  ])eriod  of  three  or  four  days.  For  the  past  five  months, 
howe\'er,  there  has  been  no  Ijleeding  whatc\-er. 

Her  color  has  been  noliccal)Iy  abnormal  for  at  least  six  years.  Four 
years  ago,  she  says,  it  v/as  worse  than  it  is  now.  Headaches  ha\e 
bothered  her  some  ])art  of  c\cry  da}-  for  many  }-ears.  They  are  aggra- 
vated by  walking,  and  affect  especially  the  occipitiil  region.  She  is 
markedly  consti])atcd,  and  notices  a  good  deal  of  mucus  in  the  stools. 
Two  years  ago  she  had  an  iUness  wliich  slie  fears  was  a  "shock,"  and 
since  that  time  she  talks  slowly  and  with  difficulty.  All  her  symptoms 
are  aggravated  in  winter,  and  she  feels  tlie  cold  very  much,  thougli  not 
more,  she  says,  than  most  ladies  of  her  age, 

Fxamination  showed  a  A'ellow,  waxv  pallor  of  the  skiii.  The  ])aticnt 
was  somewhat  obese,  but  nothing  wrong  was  detected  iii  the  internal 
viscera  or  in  the  urine,     l^lood  examination  showed: 

Red  cells.  3,600.000;  leukocytes.  6000;  hemoglobin.  .15  per  cent. 
In  the  stained  specimen  there  were  66  ])er  cent,  of  ])olynuclear  cells,  32 


574  DIFFERENTIAL  DIAGNOSIS 

per  cent,  of  lymphocytes,  and  2  per  cent,  of  eosinophiles.  The  red 
corpuscles  showed  marked  achromia  and  slight  deformities.  There 
were  no  nucleated  forms  or  abnormal  staining  reactions. 

Discussion. — The-  case  was  sent  to  me  as  one  of  pernicious  anemia, 
and  her  appearance  bore  out  this  diagnosis.  The  blood  examination, 
however,  did  not,  but  was  indicative  rather  of  a  secondary  type  of 
anemia.  It  did  not  seem  to  me  that  there  was  enough  hemorrhage 
(assuming  the  history  to  be  correct)  to  account  for  this  anemia. 

Rectal  examination  and  the  study  of  the  stools  showed  no  evidence  of  a 
rectal  or  intestinal  cancer,  and  her  good  nutrition  and  freedom  from  pain 
or  diarrhea  made  it  unnecessary  to  consider  this  diagnosis  further. 

I  learned,  during  a  subsequent  visit,  that  she  had  difficulty  in  making 
fine  motions  with  her  fingers.  Following  up  this  hint  I  tested  the  func- 
tions of  motion,  sensation,  reflex  action,  and  nutrition  without  getting 
any  new  information  except  that  the  skin  was  very  dry  and  the  nutrition 
of  the  finger-nails  notably  poor.  The  association  of  this  condition  of 
the  skin  with  slowness  of  speech  naturally  suggested  myxedema. 

On  questioning  her  I  then  learned  that  her  hair  had  been  coming 
out  very  fast,  though  she  had  thought  and  said  nothing  of  it,  supposing 
that  her  age  accounted  for  the  loss.  It  appeared,  further,  that  she  never 
perspired  unless  the  thermometer  was  above  90°  F.,  a  temperature  very 
grateful  to  her  feelings. 

Outcome. — The  patient  was  given  thyroid  extract,  2  grains  three 
times  a  day,  gradually  increased  to  5  grains  three  times  a  day.  January 
i6th  she  reported  herself  as  wonderfully  better.  March  25th  she  wrote 
that  her  hair  was  growing  tremendously,  so  that  it  was  now  thick  and 
dark.  Her  speech  had  greatly  improved,  and  her  waxy  pallor  had  dis- 
appeared. Within  a  short  time  she  was  perfectly  well,  and  has  remained 
so  up  to  the  present  time  (1910) .     She  still  takes  thyroid  extract  regularly. 

Diagnosis. — Myxedema. 

In  the  table  which  ends  the  chapter  and  in  the  diagram  which 
begins  it  I  have  grouped  causes  of  paralytic  weakness  without  any 
attempt  to  tabulate  the  cardiac  or  hemic  types  of  weakness. 


WEAKNESS 


575 


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r3  ^ 


CHAPTER  XVIII 


COUGH 


There  are,  of  course,  many  causes  of  cough  which  do  not  raise 
diagnostic  puzzles,  and  are,  therefore,  not  suitable  for  this  book.     Thus: 

(a)  "A  common  cold"  or  mild  infection  of  the  upper  air-passages, 
whether  by  the  influenzal  or  other  bacilli,  may  produce  cough  by  irritating 
the  pharynx,  larynx,  trachea,  and  larger  bronchi.  Diagnosis  is  sug- 
gested by  direct  inspection  of  these  parts,  and  by  the  absence  of  signs  in 
the  lungs  and  other  viscera.  It  is  clinched  by  the  short,  mild  course  of 
the  affection. 

(b)  In  infants  and  children  diffuse  bronchitis  often  stuffs  the  lungs 
with  squeaking  or  crackling  rales,  with  or  without  considerable  consti- 
tutional signs.  To  exclude  pneumonia  is  here  the  chief  diagnostic  task. 
Occasionally  this  cannot  be  done.  Usually  the  absence  of  marked  con- 
stitutional signs  (continued  fever,  marked  leukocytosis,  cyanosis,  drowsi- 
ness) and  of  the  physical  evidence  of  solidification  in  any  part  of  the 
lungs  excludes  pneumonia. 

(c)  The  more  obvious  "text-book"  pictures  of  phthisis  and  pneu- 
monia have  not  been  included. 

(d)  The  so-called  "stomach  coughs,"  ''uterine  coughs,"  "Hver 
coughs,"  and  other  "reflex"  irritations  from  a  distance  have  not  yet 
demonstrated  themselves  in  my  experience. 

(e)  Nasal  coughs  and  aural  coughs  still  linger  on  in  the  pages  of  text- 
books, but  I  can  find  no  convincing  evidence  that  they  exist. 

VARIETIES  OF  COUGH 

(o)  The  distinction  between  a  loose  or  productive  cough,  which  is 
associated  with  sputa  [unless  the  patient  is  too  weak  or  too  young  to 
raise  any],  and  a  dry  or  unproductive  cough,  is  verv  familiar. 

(b)  The  brassy  or  laryngeal  cough  is  a  loud,  ringing,  usually  unpro- 
ductive effort,  associated  most  often  with  aneurysms  or  tumors  pressing 
upon  the  trachea.  It  is  not  by  any  means  distinctive,  but  in  conjunction 
with  other  and  more  precise  signs  it  may  help  us  to  recognize  a  source 
of  pressure  in  the  mediastinum.  For  this  reason  it  is  often  called  a 
"pressure^'  cough. 


Causes  of  Cough 


1.  PHTHISIS 


2547 


2.  "BRONCHITIS" 


2533 


3.  MITRAL  DISEASE 


2206 


4.  TONSILLITIS 


1405 


5.  PLEURISY 


763 


6.  PHARYNGITIS 


751 


7.  MYOCARDIAL 
WEAKNESS 


587 


8.  PNEUMONIA 


521 


9.  A  O  R  T  I  C     R  E- 
GURGITAT 


JE-| 
ON  i 


517 


10.  "  INFLUENZA" 


388 


1  1.  ASTHMA 


379 


12.  EMPHYSEMA 


328 


?77 


COUGH  579 

(c)  Nervous  cough  is  sometimes  a  life-long  habit,  showing  itself 
especially  when  the  individual  is  embarrassed  or  when  he  desires  to  pre- 
empt a  pause  in  the  conversation.  Many  patients  will  undergo  a  long 
siege  of  questioning  and  physical  examination  without  showing  any  sign 
of  cough  until  we  ask  them  whether  this  symptom  is  troublesome.  With 
the  first  words  of  their  answer  there  comes  a  cough. 

Yet  it  must  be  remembered  that  in  some  cases  of  incipient  phthisis 
the  cough  seems  to  be  of  the  nervous  variety,  and  is  believed  to  be  such 
by  the  patient  and  his  family.  The  matter  can  be  settled  only  by  care- 
ful watching  and  repeated  examination. 

{d)  A  barking  cough  often  occurs  in  children  at  or  before  the  age  of 
puberty.  It  has  no  special  significance,  though  it  often  gives  rise  to 
much  alarm.  Its  explanation  is  not  known,  and  it  may  be  associated 
with  any  of  the  commoner  lesions  of  the  upper  respiratory  tract. 

(e)  A  prolonged  suffering  from  cough  is  usually  due  to  phthisis,  to 
emphysema,  or  chronic  bronchitis  with  bronchiectasis;  occasionally  to 
cardiac  insufficiency. 

(/)  Cough  on  exertion  is  usually  due  to  heart  disease,  but  may  be  the 
result  of  any  of  the  causes  mentioned  in  the  last  paragraph. 

ig)  Cough  on  change  of  position,  accompanied  by  a  profuse  dis- 
charge of  s})utum,  usually  indicates  jmlmonary  abscess  or  bronchiec- 
tasis. 

{h)  Winter  cough  recurring  each  year  is  usually  characteristic  of 
bronchiectasis.  The  cavities  remain  comparatively  dry  and  harmless 
in  the  summer-time,  but  are  prone  to  become  infected,  usually  with  the 
infiuenza  bacillus,  in  the  winter-time.  This  is  the  affection  usually 
known  as  chronic  bronchitis,  though  a  considerable  ])ercentage  of  the 
cases  so  diagnosed  are  really  due  to  pulmonary  tuberculosis. 

Case  303 

A  mule  spinner  of  forty-li\e,  of  good  family  history  and  ])ast  liistory, 
was  seen  Xovem])er  14,  1907.  He  took  gas  as  an  anesthetic  twenty 
weeks  ago  and  had  all  his  teeth  ])ullcd  out.  He  had  no  trou])le  at  the 
time,  but  a  week  later  he  i)egan  to  have  pain  in  the  right  side  of  tlie 
chest,  worse  on  deep  breath.  Two  weeks  after  the  anesthetic  lie  liegan 
to  cough,  and  noticed  that  a  bad  odor  and  bad  taste  came  into  liis  moulli; 
next  (lay  he  coughed  so  as  almost  to  choke  him.  Four  (hns  after  this  he 
began  to  raise  more  foul  s])utum  of  a  dark,  greenish-I)rown  color,  with 
dark  red  ])ortions  in  it.  On  the  third  day  lie  coughed  up  half  a  large 
bowlful  (luring  the  night.  Sometimes  the  s])utum  cann>  ru>hin^  ii]i  in 
lar<j;e  aniounts  with  \erv  little  couu;h.     The  pain  in  tlie  riu'lit  >i(le,  mean- 


58o 


DIFFERENTIAL   DIAGNOSIS 


time,  had  become  less,  the  diminution  coinciding  with  the  period  of 
excessive  sputa. 

Eight  weeks  ago  the  cough  diminished.  His  sputa  became  yellow 
and  less  foul,  and  his  appetite  improved,  as  did  all  his  other  symptoms, 
until  five  weeks  ago,  when,  as  he  stooped  to  lace  his  shoe,  blood  filled 
his  mouth,  and  he  spit  up  half  a  cupful  of  it.  Four  hours  after  he 
raised  about  the  same  amount,  and  this  continued  for  a  couple  of  days 
in  decreasing  quantities.  Since  then  he  has  not  raised  any  more  blood, 
but  his  appetite  has  been  very  poor  and  his  cough  frequent. 


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Fig.  151. — Chart  of  case  303. 


Two  and  one-half  weeks  ago  the  pain  in  the  right  side  again  became 
severe,  and  he  had  to  get  up  in  the  night  in  order  to  get  breath.  Since 
then  he  has  been  short  of  breath  on  any  exercise,  and  his  sputum  has 
again  been  foul  and  dark,  as  at  first. 

He  has  had  fever  for  fifteen  weeks,  off  and  on,  with  occasional  night- 
sweats. 

He  gave  u|)  work  on  July  20th  on  account  of  weakness,  but  he  has 
lost  very  little  weight,  as  he  was  always  thin.  The  course  of  the  tem- 
perature IS  seen  in  the  accompanying  chart. 

The  patient  is  emaciated,  the  breath  rather  foul,  the  heart  negative, 
the  right  supraclavicular  space  deeper  and  more  capacious  than  the  left. 
A  friction-rub  is  felt  in  the  riyht  axilla,  and  there  is  dulness  throucjhout 


Fig.  15^. — Area  of  rough  and  ])rolonged  exjiiration  in  Case 


COUGH 


581 


the  right  chest.  In  the  right  supraclavicular  space  and  axilla  the  percus- 
sion-note is  almost  flat.  Over  the  area  shown  in  the  diagram  (Fig,  152) 
expiration  is  rough  and  prolonged,  and  there  is  a  coarse  friction-rub 
extending  through  both  inspiration  and  expiration  over  the  whole 
right  axilla,  and  heard  more  faintly  in  front  and  behind. 

During  his  stay  in  the  hospital  the  patient  raised  daily  10  to  30  ounces 
of  mucopurulent,  foul  sputa,  containing  no  elastic  fibers  or  tubercle 
bacilli.     Its  color  was  as  described  by  the  patient. 

Later,  on  the  twenty-eighth,  the  odor  was  a  good  deal  less  marked. 

X-ray  shows  a  deep  shadow  in  the  region  of  the  right  scapula,  agree- 
ing practically  with  the  area  shown  in  the  diagram. 

Discussion. — Cough  with  foul  spvita  ejected  in  large  quantities  and 
associated  with  fever  and  sweating  suggests  four  possibilities: 

(a)  Pulmonary  abscess,  with  or  without  gangrene.^ 

(b)  Empyema  rupturing  through  the  lung. 

(c)  Phthisis  with  large  cavity. 

(d)  Bronchiectasis. 

Empyema  and  phthisis  are  improl)ablc  l)ecause  of  the  history  and 
the  condition  of  the  sputa.  The  signs  are  not  situated  in  the  parts 
generally  most  affected  by  phthisis,  and  when  that  disease  produces  a 
cavity  large  enough  to  contain  so  much  sputa,  it  is  practically  certain  to 
show  bacilli  in  great  numbers.  Empyema  is  almost  always  post- 
pneumonic, and  we  have  nothing  to  suggest  that  this  patient  has  ever 
had  pneumonia. 

The  sudden  onset  and  the  localization  of  the  signs  s])eak  against 
the  ordinary  type  of  bronchiectasis,  namely,  that  associated  with  a 
chronic  bronchitis  and  affecting  a  great  many  bronchi  almost  equally. 
Blood  is  far  less  likely  to  be  raised  in  l)ronc!iicctasis  than  in  al)sccss  or 
tuberculosis. 

After  discussing  these  alternatives,  pulmonary  abscess  seems  by  far 
the  most  reasonable  diagnosis.  Wc  have  no  clear  conception  of  the 
reason  or  method  of  its  origin ;  it  is  diflicult  to  connect  it  with  tlic  taking 
of  gas  as  an  anesthetic  unless  we  su|)])Ose  that,  under  the  influence  of 
the  gas,  lie  swallowed  something  ''the  wrong  way."'  The  histor}-  gi\es 
no  liint  of  this.  Only  by  surgical  interference  could  one  make  the 
diagnosis  any  more  certain,  and  the  results  of  such  interference  are  not 
brilliant  enough  to  make  us  willing  to  urge  it  unless  other  forms  of 
treatment  are  obviously  useless.     This  has  not  yet  been  ])r()\e(l  here. 

Outcome. — The  patient  improxed  a  good  deal  in  weight  and  >trength 

'  l'ulm<inarv  alisct-ss  ami  ])nlinotiar\-  L'aiii;rcnc  arc  cvsciitialh-  the  same  ili^ciisc.  'l"hc 
diu-  nun-  pass  into  the  (nhcr  at  an\-  tinn-  if  ilic  Dr^anisiiis  faNoriiiL;  uaiiun  lu    supcrMtif. 


^82  DIFFERENTIAL  DIAGNOSIS 

under  forced  feeding  and  sleep  out-of-doors.  He  left  the  hospital  on 
December  27,  1907. 

May  18,  1910,  he  writes:  "I  have  not  fully  recovered  from  my  sick- 
ness. I  am  able  to  go  around,  but  the  trouble  in  my  lung  has  not  healed 
yet.  I  still  cough  and  spit  as  much  as  ever.  I  have  had  a  number  of 
hemorrhages  since  I  left  the  hospital.  My  stomach  keeps  all  right,  and 
I  can  eat  most  anything  that  comes  along.  My  doctor  says  he  thinks 
my  lung  will  heal  up  m  time." 

Diagnosis. — Pulmonary  abscess. 

Case  304 

A  mill  foreman  thirty-eight  years  old  was  seen  May  4,  1908.  He 
had  "congestion  of  the  left  lung"  twelve  years  ago.  His  personal  his- 
tory and  family  history  are  otherwise  excellent. 

In  December,  1906,  he  had  a  "bad  cold"  with  a  severe  dry  cough 
which  has  continued  in  spells  ever  since.  He  sometimes  coughs  so 
hard  that  he  faints  away,  and  it  is  very  difficult  for  him  to  get  his  breath 
at  these  times;  yet  he  may  go  for  a  week  without  any  cough  whatever. 
His  appetite  is  good,  his  bowels  regular  and  he  sleeps  well,  except  during 
the  spells  of  coughing.  He  has  no  digestive  or  urinary  symptoms,  and 
has  lost  no  weight. 

Physical  examination  shows  a  finely  developed,  strong-looking  man, 
with  a  hoarse  voice  and  occasional  ringing  cough.  There  are  numerous 
dark-red  papules  scattered  over  the  chest.  The  pupils  are  equal,  circular, 
and  react  normally.  Harsh,  noisy  respiration  is  heard  over  the  whole 
of  both  lungs.  There  seems  to  be  some  slight  dulness  toward  the  top 
of  the  right  axilla.  The  abdomen  is  slightly  distended  and  held  rather 
firmly.  It  is  tympanitic  throughout.  The  patient  seems  entirely 
comfortable,  exce])t  for  the  coughing  spells,  at  times  excessively  severe. 
The  urine  is  negative.  The  white  cells  are  from  12,000  to  15,000. 
There  arc  no  abnormal  areas  of  dulness  or  pulsation.  The  heart  is 
negati\e.  The  right  pulse  is  distinctly  larger  than  the  left;  indeed, 
the  left  is  hardly  palpable. 

The  patient  went  back  to  business  on  March  gth. 

Discussion, — Intense  paroxysmal  cough  in  children  usually  means 
pertussis;  in  adults  one  would  not  make  such  a  diagnosis  without  a  very 
circumstantial  history  unless  we  had  heard  the  typical  "whoop." 

If  the  patient  had  had  bronchitis  for  so  long  a  period,  he  should  be 
either  better  or  worse.  He  should  have  more  sputa  and  more  signs  in  the 
lungs. 


COUGH 


583 


If  tuberculosis  were  at  work,  there  would  be  more  emaciation, 
fever,  and  other  constitutional  symptoms.  In  tuberculosis,  moreover, 
the  cough  is  not  often  so  violent,  paroxysmal,  and  intermittent. 

Obscure  and  violent  cough  is  often  due  to  pleural  irritation,  such 
as  occurs  at  the  onset  of  acute  pleurisy  or  when  foreign  bodies  irritate 
the  surface  of  the  lung.  But  there  seems  no  evidence  of  any  source  of 
irritation  in  this  case. 

Malignant  disease  of  the  lung,  pleura,  or  mediastinal  glands  should 
always  be  considered  in  obscure  diseases  of  the  respiratory  tracts. 
Diagnosis,  however,  is  impossible  unless  there  is  a  pleural  effusion, 
some  pulmonary  signs  corresponding  to  an  inliltration  of  the  lung  or 
pleura,  or  radiating  pressure  pains.  Except  for  the  slight  dulness, 
made  out  rather  doubtfully  toward  the  top  of  the  right  axilla,  we  have 
nothing  corresponding  to  any  circumscribed  pulmonary  or  ])leural 
lesions.  This  questionable  dulness  is  not  a  sufficient  basis  for  any 
diagnostic  hypothesis. 

Most  significant  in  this  case,  as  in  any  invohing  hoarseness  and  a 
ringing  })aroxysmal  cough,  is  the  difference  between  the  two  pulses. 
Indeed,  in  the  presence  of  these  three  symptoms  we  should  always 
sus])ect  aneurysm,  with  malignant  tumor  as  a  less  prolmblc  alternative. 
It  is  ])ossible,  of  course,  that  the  difference  of  the  pulses  may  represent 
nothing  ])ut  a  congenital  anomaly.  Such  idiosyncracies  are  not  un- 
common, but  they  are  rarely  associated  with  the  rest  of  the  symptom 
grou])  above  described.  To  arri^■c  at  any  greater  certainty  regarding 
the  diagnosis  we  need,  first  of  all,  an  examination  of  the  vocal  cords. 
If  one  cord  is  found  to  be  in  the  cadaveric  position,  we  may  conclude 
that  the  left  recurrent  laryngeal  nerve  is  being  pressed  u])on  by  an 
aneurysm  or  a  tumor.  Further  evidence  would  be  furnished  by  v-ray 
examination. 

Outcome. — Radioscopy  showed  a  pulsating  shadow  corres])onding 
to  that  ordinarily  found  in  aneurysm  of  the  aortic  arch,  l^xamination 
of  the  vocal  ccjrds  showed  no  paralysis  of  the  recurrent  laryngeal  nerve 
and  no  ol)struction  of  the  trachea.  March  9th  the  ])atient  went  back  to 
business,  considerably  improved  by  his  rest,  ]iossibly  also  b}-  the  jtotas- 
sium  iodid  which  he  took  in  lo-grain  doses  throughout  the  ])eri(Ki  of 
treatment. 

A  notable  feature  of  this  case  is  the  absence  of  any  pain  or  an}-  sign 
of  pressure  other  than  the  cough,  the  hoarseness,  and  the  ine<iuality  of 
the  pulses. 

Diagnosis. — Aneurysm. 


584 


DIFFERENTIAL  DIAGNOSIS 


Case  305 

A  school-girl  seven  years  old  has  had  "asthma"  about  once  a  month 
for  the  past  two  years,  but  has  otherwise  been  well. 

Two  weeks  ago  she  caught  cold  and  had  a  bad  cough,  but  stayed 
at  school  until  a  week  ago.  Yesterday  her  cold  was  worse  and  she 
went  to  bed.  To-day  she  has  vomited  three  times.  Her  bowels  are 
loose  as  a  result  of  "Father  John's  Medicine." 

At  entrance,  November  9,  1907,  the  breathing  was  rapid,  but  not 
labored;  cheeks  flushed,  lips  dry  and  fissured.  There  was  a  crop  of 
herpetic  vesicles  about  one  corner  of  the  mouth. 
The  glands  in  the  neck,  axillae,  and  groins  were 
somewhat  enlarged.  The  heart's  impulse  ex- 
tended to  the  nipple-line  in  the  fourth  space.  Its 
action  was  regular,  and  the  sounds  were  of  good 
quality.  The  pulmonic  second  sound  was  louder 
than  the  aortic  second.  In  the  right  back  the 
breathing  was  rough  from  the  apex  to  the  angle  of 
the  scapula,  accompanied  by  squeaks  and  increase 
of  voice-sounds.  The  abdomen  was  flat,  spastic, 
and  very  tender  throughout,  especially  in  the  right 
lower  quadrant.  Nothing  else  could  be  felt.  By 
rectum,  there  was  general  tenderness,  nothing 
more  distinctive. 

The  coui'se  of  the  temperature  is  seen  in  the 
accompanyhig  chart  (Fig.  153). 

White  cells,  30,200;    urine,  normal. 
A  surgeon  ])romptly  saw  the  case  and  thought 
that  her  symptoms  were  all  due  to  the  lung  in- 
vohemcnt.     Next  morning  the  belly  was  much  less  tender,  and  by  the 
eleventh  the  lung  signs  were  also  very  slight. 

The  child  was  pale  and  looked  delicate.  The  sputum  was  repeatedly 
examined,  without  any  jjositive  result. 

From  the  fourteenth  to  the  eighteenth  the  child  got  steadily  worse; 
she  woke  frcciuently  in  the  night  crying  with  pain,  relie\-ed  to  some 
extent  by  llaxseed  ])()ulticcs  to  the  abdomen.  There  was  some  dulness, 
with  diminished  breathing  in  the  right  back  and  lower  axilla.  The 
right  thigh  was  now  held  Hexed  upon  tlie  abdomen. 

Discussion. — We  have  been  warned  so  often  of  late  that  when- 
ever a  child  seems  to  have  something  wrong  in  his  abdomen  we  should 
always  consider  and  in\estigate  the  chest,  that  we  naturally  make  the 


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-Chart  of  case 
305- 


COUGH 


585 


effort  to  explain  in  this  way  all  this  little  girl's  symptoms.  The  thoracic 
diseases  which  ordinarily  produce  abdominal  pain  in  children  are  pneu- 
monia and  pleurisy,  but  this  child  shows  no  evidence  of  either  of  these. 
A  moderate  degree  of  bronchitis,  such  as  might  be  the  outcome  of  an 
ordinary  cold  or  the  begmning  of  a  tuberculosis,  is  what  we  find.  Neither 
of  these  diseases  is  prone  to  make  the  abdomen  spastic  and  tender,  but 
the  presence  of  a  herpes  makes  us  wonder  whether  there  may  not  be  some 
deep-seated  pneumonic  process  which  we  have  overlooked. 

As  the  lungs  cleared  up,  the  condition  of  the  abdomen  did  not. 
Thereby  the  focus  of  attention  was  shifted,  and  we  began  to  ask  our- 
selves more  seriously  what  was  wrong  there.  Appendicitis  is  not  com- 
mon in  children  of  this  age,  and  is  not  often  associated  with  herpes. 
Nevertheless,  it  seems  more  probable  than  any  other  condition.  The 
psoas  spasm  might  be  explained  in  this  way,  especially  as  there  seems 
to  be  no  lesion  of  the  hip,  spine  or  urinary  tract. 

Some  discussion  arose  in  this  case  regarding  the  significance  of  the 
leukocyte  count.  Since  children  have  naturally  a  higher  leukocyte 
count  and  greater  diurnal  variations  than  adults,  some  of  those  who 
saw  this  child  were  in  doubt  whether  a  count  of  30,000  was  markedly 
abnormal  under  the  circumstances.  It  seemed  to  me  clear,  however, 
that  such  a  count  should  be  interpreted  as  a  well-marked  leukocytosis, 
since,  in  children  of  this  age,  the  blood  has  practically  always  attained 
to  conformity  with  the  adult  type. 

Outcome. — On  tlic  eighteenth  the  al^domcn  was  oj)cned  and  about 
4  ounces  of  ])us  were  removed  from  the  region  of  the  a])pendix. 

There  is  no  question  that  Ijronchitis  was  also  ])rescnt  here,  and  after 
the  study  of  a  good  many  similar  cases — some  of  which  devcloT)cd 
appendicitis,  others  endocarditis  or  multij)le  arthritis,  while  still  others 
remained  as  an  unlocalized  pyogenic  infection  of  the  blood-stream — 
it  seems  to  me  at  least  ])ossible  that  the  a])])endicitis  which  results  in  a 
case  like  that  here  discussed  re])resents  the  outcome  or  localizatioii  of 
a  general  ])y()genic  infection. 

Diagnosis. — Bronchitis  and  appendicitis. 

Case  306 

A  Russian  picture-frame  maker,  thirtA-tliree  years  old.  who  has  l)ccn 
three  years  in  this  country,  entered  the  hospital  Septcnibcr  J4.  iwo;. 
He  has  ne\er  been  sick  before.  His  habits  and  family  hi>tor}-  arc- 
excellent.  He  was  suddenl)-  seized,  three  Mceks  ago,  with  (•]iill>  and 
fe\cr  and  ])ain  through  both  sides  of  his  chest.  Tlu'  next  da\-  he  began 
to  coui:h,  and  the  luiin  became  confined  to  tlie  let't  ehe>t.    'I'he  aniictite 


586 


DIFFERENTIAL  DIAGNOSIS 


remained  good,  but  for  the  last  two  nights  he  has  slept  poorly  on  ac- 
count of  dyspnea,  which  makes  it  almost  impossible  for  him  to  lie 
down. 

When  examined,  he  was  breathing  jerkily.  His  lungs  were  hyper- 
resonant  throughout,  expiration  prolonged,  feeble,  and  accompanied 
by  squeaks  and  crackles.  In  the  left  axilla,  from  the  fifth  rib  down- 
ward, a  friction-rub  could  be  felt  and  heard.  It  was  most  marked 
during  expiration.     Visceral  examination  was  otherwise  negative. 

The  white  cells  were  5000;  the  urine  normal;  there  was  no  fever 
during  his  week  in  the  hospital.  The  patient  was  given  an  ice-bag 
o\er  the  painful  side;  h  grain  of  codein  every  two  hours  when  needed; 
fluid  extract  of  grindelia  robusta,  20  minims  every  twenty  minutes  for 
four  doses;  then  30  minims  every  three  hours.  His  chest  pain  was 
relieved  by  strapping  the  chest. 

Discussion. — When  pain  is  complained  of  in  both  chests  by  one  who 
is  suffering  from  a  cough,  it  usually  represents  the  result  of  muscular 
soreness  due  to  the  cough  itself.  Occasionally  it  is  produced,  like 
headache  and  backache,  by  the  infectious  agent  which  has  caused  the 
cough.  At  first  sight  it  seems  that  pleurisy  would  be  a  simpler  explana- 
tion, at  any  rate  for  the  left-sided  pain;  but  as  we  scrutinize  the  report 
more  carefully  and  note  that  the  friction  was  most  marked  during  ex- 
piration, we  begin  to  doubt  whether  it  really  was  a  friction — i.  e.,  whether 
it  was  due  to  a  pleurisy.  Pleural  frictions  are  almost  never  exaggerated 
during  expiration.  The  end  of  inspiration  is  the  favorite  time  for  their 
appearance  and  their  usual  period  of  maximum  intensity.  But  there 
is  another  phenomenon  not  infrequently  mistaken  for  pleural  friction, 
and  especially  apt  to  occur  during  expiration — I  mean  the  snoring  rale 
which  can  often  be  felt  as  well  as  heard,  and  which  is  ay)t  to  occur 
in  chests  presenting  the  group  of  physical  signs  here  recorded. 

The  most  salient  point,  however,  about  this  case  is  the  presence  of 
cough  without  fever.  Such  a  cough,  associated  with  the  group  of 
signs  just  referred  to,  is  especially  characteristic  of  the  spasmodic  or 
asthmatic  type  of  bronchitis.  Indeed,  one  would  proceed  straight 
way  to  make  this  diagnosis,  provided  he  had  adequately  considered 
two  other  possibilities  which  should  always  haunt  us  when  we  make  a 
diagnosis  of  asthma  or  asthmatic  bronchitis.     I  refer  to : 

(a)  Sy])hilis  invohing  aortic  aneurysm  or  stenosis  of  a  bronchus. 

(b)  Pulmonary  tuberculosis. 

Any  one  who  remembers,  as  I  do,  the  disgrace  of  being  confronted 
at  autopsy  with  aneurysm  or  syphilitic  stenosis  of  the  bronchus  in  a 
case  which  he  has  treated  durine;  life  for  asthma  will  never  be  hastv 


COUGH 


587 


again  in  making  the  latter  diagnosis.  The  wheezing  and  coughing 
produced  by  one  of  the  varieties  of  syphilis  above  referred  to  may  be 
clinically  identical  with  those  of  ordinary  bronchial  asthma.  The 
treatment  often  relied  upon  for  asthma  (large  doses  of  potassium  iodid) 
may  still  further  mislead  us  through  the  improvement  it  produces  in 
syphilitic  infections.  Indeed,  one  sometimes  is  led  to  wonder  whether 
this  is  not  the  explanation  for  the  reputation  of  potassium  iodid  in  the 
treatment  of  asthma. 

In  a  paper  by  Dr.  Cleaveland  Floyd  *  we  are  warned  how  frequently 
cases  of  asthma  and  emphysema  with  chronic  bronchitis  mask  the 
development  of  a  pulmonary  tuberculosis. 

Both  these  possibilities  were  considered  in  the  present  case,  and 
everything  was  done  to  discover  evidence  of  their  presence.  Nothing 
of  the  kind  came  to  light,  however,  and  with  reasonable  certainty  these 
haunting  possibilities  may  be  excluded  by  the  outcome. 

Outcome. — By  the  thirtieth  of  September  the  physical  signs  were 
gone  and  the  patient  was  allowed  to  go  home.  His  health  has  since  then 
remained  good,  though  he  has  occasional  attacks  of  wheezing. 

Diagnosis. — Bronchitis  and  asthma. 

Case  307 

A  hospital  nurse,  twenty-eight  years  old,  was  seen  May  4,  1907.  She 
was  never  sick  until  three  weeks  ago,  when  she  had  "grip,"  but  kept  v)n 
duty  until  the  right  ear  began  to  ache  twelve  days  ago;  the  drum  was 
tapped  ten  days  ago,  with  a  copious  discharge  of  pus  containing  strej)to- 
cocci.  At  the  right  base,  below  the  angle  of  the  scapula,  were  num- 
erous crackling  rales.  Tater  these  rales  gradually  extended  over  the  rest 
of  both  lungs.  The  white  cells  ranged  between  18,000  and  21,000. 
Physical  examination  was  otherwise  negative.  Now  she  complains  of 
anorexia,  Insomnia,  cough,  fever,  and  weakness.  There  is  no  longer 
any  tenderness  about  the  ear. 

On  the  tenth  the  ])atient  was  mildh'  delirious,  res])iration  shallow 
and  almost  stertorous,  j)ulse  falling  steadily,  but  of  poor  volume  and 
tension.  Acute  redness  and  tenderness  now  devel()])ed  over  the  tendons 
of  l)otli  wrists.  All  this  time  there  had  been  a  continuous  discharge 
from  the  right  ear,  l)ut  there  was  a])])arently  good  drainage  and  no  mas- 
toid tenderness  or  etlema. 

The  patient's  extreme  ncr\ousness  suggested  cere])ral  irritation. 
Accordingly,  on  the  tenth  of  March  the  right  mastoid  was  o])cnc(l  and 
curetted,  a  good  deal  of  pus  l)eing  found  and  remo\c(l.     The  lateral 

'  lioslnn  Med.  and  Sur^.  J"Ur.,   i()0(),  vn].  rlxi,  ]>.  407. 


588 


DIFFERENTIAL   DIAGNOSIS 


sinus  was  laid  bare,  and  a  needle  introduced  into  it.  Pure  sterile  blood 
was  withdrawn.     Infection  of  the  sinus  was  thus  excluded. 

Discussion.— In  this  patient  we  find  the  signs  of  bronchitis  only, 
but  she  is  obviously  too  sick  for  mere  bronchitis  of  the  ordinary  type. 
This  particular  combination  of  the  signs  of  bronchitis  with  constitu- 
tional manifestations  too  grave  to  be  thus  explained  is  very  familiar 
in  voung  children,  and  under  those  conditions  is  well  known  to  mean 
bronchopneumonia,  provided  evidence  of  disease  in  other  organs  is 
wanting.  In  adults  this  particular  combination  or  contradiction  is  much 
less  common. 

It  is  quite  possible  that  this  patient  had  bronchopneumonia,  but 
we  do  not  need  to  assume  it,  for  the  lesions  of  the  middle  ear  and  of 
the  tendon-sheaths  furnish  abundant  evidence  of  a  generalized  pyogenic 
infection  sufficient  to  explain  why  this  patient  is  so  sick. 

It  is  just  within  the  bounds  of  possibility  for  a  generalized  tubercu- 
losis to  begin  in  this  way,  but  the  presence  of  streptococci  in  the  aural 
discharges  and  the  absence  of  tubercle  bacilli  from  the  sjjuta  give  us  no 
ground  for  following  this  idea  any  further. 

After  the  drainage  of  the  mastoids  the  pulmonary  signs  did  not  clear 
up,  and  the  sputum  was  repeatedly  reexamined  for  evidence  of  tuber- 
culosis, always,  however,  with  negative  results.  In  an  older  person 
with  a  bigger  heart  we  should  have  been  probably  in  considerable  doubt 
whether  the  pulmonary  rales  were  due  to  edema  or  to  inflammation,  to 
a  transudate,  or  an  exudate.  Not  infrequently  these  two  states  are  so 
mixed  up  in  elderly  people  that  the  fine  gradations  between  bronchitis, 
edema,  hypostatic  pneumonia,  and  lobar  pneumonia  cannot  be  dis- 
tinguished. In  the  present  case,  however,  there  is  no  occasion  for  any 
such  speculation.     The  heart  was  of  good  strength  throughout. 

Outcome. — In  the  course  of  two  weeks  the  patient's  recovery  was 
nearly  complete,  though  some  rales  remained  in  the  lung,  e\en  after 
the  mastoids  were  entirely  healed. 

Diagnosis. — Streptococcus  bronchopneumonia. 

Case  308 

A  school-boy  of  sexentcen  entered  the  hospital  January  20,  1908. 
He  had  liad  "pneumonia''  when  he  was  four  years  old,  and  again  when 
he  was  seven.  P\)ur  years  ago  lie  had  "general  peritonitis,"  for  which 
he  was  operated  upon  at  the  Boston  City  Hospital.  He  also  had 
measles  and  mumj)s  in  infancv. 

For  the  last  three  years  he  has  Ijcen  Ijotliercd  l)v  a  persistent  cough 
-vith   a])undant  s})utum.     The  cough   is  se\ere  enough   to  make  him 


COUGH 


589 


vomit  about  once  a  week  after  breakfast.  He  loses  much  sleep  on  ac- 
count of  the  cough. 

Five  times  in  the  past  year  his  sputum  has  been  blood-streaked, 
the  last  time  four  days  ago,  when  there  were  small  black  clots  in  it. 
He  has  no  night-sweats,  and,  so  far  as  he  knows,  no  fever.  (See  chart 
for  temperature.) 

His  appetite  has  been  good,  his  bowels  regular,  his  sleep  good  exccjjt 
when  disturbed  by  cough. 

Physical  examination  shows  that  the  boy  is  distinctly  undersized. 
His  present  weight  is  76  pounds.  He  has  a  "chicken  breast."  The 
heart  is  negative.  The  lungs  are  tympanitic 
throughout,  with  scattered  rales  of  various 
sizes,  especially  numerous  in  the  right  axilla 
and  at  the  right  base  behind.  There  are 
two  operation  scars  in  the  right  and  in  the 
left  lower  quadrant  of  the  abdomen.  The 
fingers  are  markedly  clubbed,  the  nails 
curved  horizontally  and  laterally;  slight 
clubbing  of  the  toes  also.  The  blood  and 
urine  are  normal.  His  sputum  is  of  a  very 
offensi\e  odor. 

Discussion. — Chronic  cough  associated 
with  cluljljcd  fingers  in  a  young  boy  with 
a  sound  heart  means  usually  one  of  three 
things: 

(a)  Chronic  bronchitis  with  bronchi- 
ectasis. 

(b)  Chronic  pleurisy,  serous  or  j)urulcnt. 
(r)    Phthisis. 
A  j)ulmonary  abscess  could  not  have  lasted  so  long  without  ])roduc- 

ing  more  definitclv  circumscribed  physical  signs  in  the  affected  lung. 
\\"e  should  be  practically  sure,  also,  to  find  a  history  of  the  discharge 
of  large  (juantities  of  s])utum  within  a  short  time  when  tlie  caNity  was 
emptied  out. 

Returning  now  to  the  three  alternati\es  mentioned  abo\e.  it  seems 
certain  that  the  ])hysical  signs  would  l)e  far  more  marked  and  e.\ten>i\e 
if  pulmonary  tuberculosis  had  been  at  work  for  three  years.  (  H  cour.-e. 
the  sj)uta  must  ])e  carefully  and  repeatedly  examined.  A  dozen  neL:ati\e 
examinations  in  succession  would  constitute  strong  e\i(len('e  against 
tuberculosis. 

All  lyi)es  of  ])leurisy  can  be  easilv  ruled  out.     There  \\  ould  l>e  marked 


Pig.   154. — Chart  of  case 


590  DIFFERENTIAL   DIAGNOSIS 

flattening  of  one  chest,  displacement  of  the  heart,  and  much  more 
characteristic  physical  signs  than  are  here  reported. 

If  tubercle  bacilli  are  ])roved  to  be  absent,  the  only  reasonable 
conclusion  will  be  that  this  boy  is  suffering  from  a  bronchiectasis, 
])robably  with  secondary  infection  of  the  dilated  bronchi  by  influenza, 
the  usual  iniiabitant  of  such  diseased  tubes.  Between  the  enlarged 
bronchi,  pulmonary  tissue  becomes  condensed  and  more  and  more 
atro])hic. 

Conclusive  evidence  may  ^•ery  possibly  be  obtained  by  means  of 
.r-ray  examination,  which  is  especially  valuable  in  young  subjects  with 
thin  chest-walls. 

Outcome. — Examination  of  the  abundant  purulent  sputa  was  per- 
formed many  times.  Pneumococci,  streptococci,  and  influenza  bacilli 
were  present  always;  tubercle  Ijacilli  never.  X-ray  examination  showed 
shadows  suggestive  of  a  numl:)er  of  dilated  bronchi.  The  diagnosis 
of  bronchiectasis  seemed  reasonabh-  certain. 

A  vaccine  made  from  the  influenza  baciUi  isolated  from  the  boy's 
sputa,  was  injected  a  number  of  times,  but  had  no  ob^•ious  effect  except 
to  increase  the  amount  of  sputum,  a  change  which  was  noted  after  each 
injection. 

This  patient  reentered  the  hospital  September  3,  1908,  and  died  of 
pneumonia  after  an  illness  of  six  days. 

Diagnosis. — Bronchiectasis. 

Case  309 

A  rag-sorter  of  fifty-six  entered  the  hospital  June  13,  1907.  He 
has  always  been  well  except  for  a  slight  cough  during  the  last  three 
years.  His  family  history  is  excellent.  He  has  been  much  more 
annoyed  than  usual  during  the  last  four  weeks  by  a  cough  accom- 
panied by  viscid,  scanty  sputa.  He  has  had  pain,  first  in  the  right 
chest,  now  in  the  left.  There  has  been  no  fever,  but  much  weakness. 
The  arteries  are  palpable  and  tortuous,  his  fingers  clubbed.  Scattered 
throughout  the  lungs  arc  many  fine  and  coarse  rales;  the  lungs  are 
generally  hyperresonant.  the  breathing  strongly  suggestive  of  emphysema. 
The  rales  arc  more  numerous  at  the  base  of  each  axilla.  Near  the  verte- 
bral lx)rder  of  the  left  scapula  there  is  a  patch  of  pure  bronchial  breath- 
ing about  the  size  of  a  silver  dollar.     (Sec  Figs.  155  and  1:^6.) 

The  leukocytes  are  17.000;  urine,  normal;  sputa  abundant,  muco- 
purulent, containing  a  few  pneumococci;  nothing  else  of  interest. 

Discussion. — The  history,  the  social  condition  of  the  patient,  the 
physical  signs,  and  the  clubbed  fingers  suggest  a  chronic  bronchitis  with 


tig.  155. —  Areas  of  cardiac  and  hepatic  (iulness  in  Case  309;   also  position  of  r;*des  (crosses), 


I'iu;.    ;5r>.— I\t-^ull>   of   austullation    and    jierciis-^ion    in    ('a>t'    :;ci).      'I'lncc    \tais'    coui^h; 

tlulilii'd  linuer-^. 


COUGH 


591 


bronchiectasis,  but  from  the  nature  of  the  present  complaints  it  would 
seem  that  something  more  acute  must  be  going  on,  especially  as  there  is 
a  patch  of  bronchial  breathing  in  the  left  back.  How  is  this  to  be 
explained? 

Bronchopneumonia  and  tuberculosis  are  the  chief  possibilities. 
Of  tuberculosis  there  is  as  yet  no  evidence,  but  we  have  not  yet  watched 
the  case  long  enough  to  have  any  right  to  confidence  on  this  point. 
Cases  beginning  ^^•ith  signs  like  these  often  continue  for  months  and 
years  without  any  proof  of  our  suspicions  of  tuberculosis,  until  finally 
a  sputum  examination  is  positive.  Many  such  cases  deserve  to  be 
treated  as  tuberculous  long  before  we  can  prove  them  to  be  so. 

It  is  quite  possible,  however,  that  we  are  dealing  in  this  case  with 
nothing  more  dangerous  than  one  of  those  attacks  of  bronchopneumonia 
so  apt  to  occur  from  time  to  time  in  the  course  of  a  chronic  bronchitis 
with  bronchiectasis.  Indeed,  it  is  sometimes  convenient  to  divide  this 
disease  into  three  phases: 

(a)  The  summer  phase. 

(b)  The  winter  phase. 

(c)  The  bronchopneumonic  attacks. 

In  summer  it  may  be  nothing  but  a  little  wheezing  induced  by  exer- 
tion or  by  laughing;  in  winter  we  get  infection  of  the  bronchiectatic 
cavities  with  influenza;  profuse  ])urulcnt  discharge  and  paroxysms  of 
coughing,  diurnal  and  nocturnal,  are  the  result. 

At  any  time  there  may  l)e  acute  febrile  attacks,  with  or  without 
definitely  localized,  demonstral^le  foci  of  solidification,  such  as  are  here 
dcscri])ed.  The  vast  majority  of  such  attacks  run  a  favorable  course 
within  a  few  weeks.  They  are  associated  with  a  good  deal  more  wheez- 
ing and  a  more  a])undant  nummular  s])utum  than  is  usual  in  lol)ar 
pneumonia. 

Outcome. — By  June  21st  the  signs  liad  practically  disappeared  from 
tlie  left  chest,  and  the  patient,  though  not  well,  was  in  api)roximatcly 
the  same  condition  as  ])ef()rc  his  acute  attack.  He  \vas  accordingly 
allowed  to  go  home. 

Diagnosis. — Bronchitis;  bronchopneumonia,  l)r()nchicctasis,  and 
emphysema. 

Case  310 

A  nurse  of  twenty-four  entered  the  hospitid  "May  5,  tqo;.  She  lias 
always  previously  been  well,  and  has  an  excellent  family  history.  I'or 
a  week  slie  has  had  a  bad  cold,  with  headache,  loss  of  a])petitc\  cough, 
and  frothy  while  sputum. 


592 


DIFFERENTIAL  DIAGNOSIS 


The  course  of  the  temperature  is  seen  in  the  accompanying  chart. 
The  breathing  above  the  third  rib,  in  the  right  front,  is  much-diminished, 
occasionally  of  cog-wheel  type,  and  accompanied  by  crackles  and 
squeaks.  There  is  a  friction-rub  in  the  right  axilla.  Visceral  examina- 
tion is  otherwise  negati^•e,  as  is  the  blood,  the  urine  and  the  sputum. 
Gradually  an  area  of  dulness  developed  in  the  right  axilla  and  spread 
over  the  whole  right  chest  by  the  thirteenth  of  May,  with  flatness  below 
midscapula    and    intense    bronchial    breathing.     Many    crackles   and 

friction-sounds  were  heard  over 
this  area.  The  white  cells  con- 
tinued low  (7000).  The  sputum 
was  repeatedly  examined,  with 
negative  results. 

On  the  nineteenth  a  trocar 
was  introduced  in  the  right  pos- 
terior axillary  line,  ^  inch  below 
the  angle  of  the  scapula.  It 
appeared  to  enter  solid  lung,  and 
no  fluid  was  withdrawn. 

By  the  twenty-second  she  had 
regained  her  appetite,  and  al- 
though pale  and  emaciated,  was 
in  good  spirits.  The  physical 
signs  were  as  previously  described, 
except  that  the  rales  and  the 
pleural  rubs  were  now  practically 
gone. 
By  the  twent\'-fifth  dulness  was  less  marked;  the  breathing  broncho- 
vesicular  or  vesicular. 

On  the  twenty-ninth  dulness  persisted  in  the  right  axilla  and  a  little 
in  front,  but  there  was  none  in  the  back,  and  the  breath-sounds  were 
there  normal,  while  in  front  they  were  still  bronchovesicular,  with  an 
occasional  crackle. 

Discussion. — -The  case  looks  alarmingly  like  one  of  consumption, 
in  spite  of  its  acute  onset.  The  physical  signs  are  by  no  means  distinc- 
tive, but  through  the  earlier  part  of  the  disease  are  perfectly  consistent 
with  tuberculosis.  One  could  only  attain  greater  certainty  at  this 
period  of  the  disease  l^y  repeated  sputum  examinations  and  by  the 
cutaneous  tuberculin  tests  (valuable,  if  negative). 

The  onset  is  very  unlike  that  of  ordinary  pneumonia.  Flatness  on 
percussion,  such  as  was  observed  about  the  thirteenth  of  May,  almost 


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^f^m    iriiumi    m  A;    \&  J«    .r-:    rrji    lysj 

Fig.  157. — Chart  of  case  310. 


COUGH 


593 


never  occurs  in  true  pneumonia,  and  in  the  great  majority  of  cases 
indicates  free  fluid.  I  am  alluding  here  to  flatness  used  in  the  strict 
sense,  and  in  contradistinction  from  dulness.  It  was  for  this  reason 
that  the  exploratory  puncture  was  done  despite  the  presence  of  bronchial 
breathing  and  r^es.  It  is  of  great  importance  to  remember  that  fluid 
has  again  and  again  been  obtained  through  a  needle  inserted  at  a  point 
where  bronchial  breathing,  rales,  or  both  were  clearly  audible. 

The  result  of  tapping  excluded  fluid  at  that  date,  though  it  seems  to 
me  quite  possible  that  an  effusion  had  previously  been  present.  The 
tapping  seems  to  me  entirely  justified,  for  there  was  a  good  deal  in  the 
aspects  of  the  case  on  the  nineteenth,  which  suggested  a  postpneumonic 
empyema  and  only  tapping  could  rule  this  out. 

Once  this  result  was  obtained,  the  balance  of  probabilities  was  again 
in  favor  of  pneumonia.  One  further  possibility,  however,  remained, 
\iz.,  interlobar  empyema,  a  complication  always  difficult  of  recognition, 
though  not  uncommon. 

How  is  the  low  white  count  to  be  explained?  The  patient  was  ne\er 
in  that  condition  of  desperate  illness  which  we  associate  with  most  cases 
of  pneumonia  without  leukocytosis.  Indeed,  she  was  never  in  any  con- 
dition calling  for  anxiety.  In  all  probability  the  disease  was  due  to 
some  organism  other  than  the  pneumococcus.  Clinically,  the  course 
was  distinctly  atypical.  Both  the  physical  signs  and  the  leukocyte  count 
were  distinctly  "queer,"  but  not  enough  is  known  as  yet  regarding  the 
pneumonias  due  to  organisms  other  than  the  pneumococcus  to  enable 
us  to  recognize  the  definite  types,  such  as  streptococcous  pneumonia  or 
influenzal  pneumonia. 

Outcome. — By  June  2d  the  breath-sounds  were  ever}-whcrc  normal, 
the  rales  gone,  the  dulness  very  slight.  Her  convalescence  was  unevent- 
ful thereafter. 

Diagnosis. — Pneumonia. 

Case  311 

A  clerk  of  eighteen  entered  the  hos])ital  June  24,  IQ07.  His  family 
history  was  excellent.  He  had  ne\er  been  sick  until  the  prc-ent  time. 
A  week  ago  he  woke  up  coughing  and  raising  bloody  sputum;  in  all, 
about  two  teaspoonfuls.  He  had  then  no  j)ain.  \"()n'iiting.  or  fe\-er. 
From  this  time  on  he  continued  to  ha\e  cough  and  l)egan  to  be  short 
of  breath.  He  has  been  weak  and  has  ke])t  his  bed.  (See  chart  for 
teini)erature.  and  diagram  for  condition  of  the  kings.) 

rhN"si(~al   examination   was  otlierwise   negaliNc;   white   (.ells.   8000: 
urine  normal.      The  .sputa  was  examini'd  three  times  for  tuhert  le  bacilH. 


594 


DIFFERENTIAL  DIAGNOSIS 


but  nothing  found.  The  patient  had  a  good  appetite,  and  did  not  seem 
especially  sick.  During  his  stay  in  the  hospital  he  raised  no  more  blood, 
but  the  signs  extended  untU  most  of  the  left  lung  was  involved.  Later 
the  base  cleared  very  much,  but  at  the  left  apex,  both  front  and  back, 
there  remained  bronchial  breathing,  cracklmg  rales,  and  increased  fre- 
mitus. Near  the  anterior  fold  of  the  right  axilla  amphoric  breathing 
and  "cracked-pot  sound"  were  obtained. 

Discussion. — The  onset  is  not  typical  of  any  of  the  commoner  res- 
piratory diseases,  and  pneumonia  should  have  fever  and  leukocytosis 
from  the  beginning,  even  when  cough  and  sputa  are  absent.  On  the  other 
hand,  the  signs  remind  us  more  of  pneumonia  than  of  anything  else, 


4  J.   r\^,,..,    .J....|.ri,.ol.«[.,UL|^ 

1.^—      1^1';      /!    1/    ,1  n 

3/|    „-^       1      X,-^  n'i^,r   \ni\   i/ 

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. 

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j    1    1    1                         ■.    :    1 

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i      '           1  1      'M      1        ! 

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w          [  M  !(i.i  M  ' 

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t  ;;  %f\i..J     i^,'v*_„ 

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«  „  1    ^^^.        ^  , 

'     :     1         i     i     !     '   ■        1     .     ,     1     ■     1 

I'^y-'-i  -'         v,i    '    ,/rt    . 

r;A„'    r^      ^,  1  '-'Ili  .''^  .  >^' 

I'^ig.  158. — Chart  of  case  311. 


and  as  the  condition  persists  it  is  natural  to  ask  whether  we  may  not 
be  dealing  with  a  failure  of  resolution.  I  have  already  said,  however, 
in  the  discussion  of  pre\ious  cases,  that  unresolved  pneumonia  usually 
turns  out,  in  my  experience,  to  be  a  mistake  in  diagnosis,  the  actual  con- 
dition being  postj)neumonic  empyema. 

One  would  hardly  make  a  diagnosis  of  this  latter  condition,  however, 
unless  one  had  better  reason  to  believe  in  the  original  pneumonia.  But 
there  is  no  such  difficulty  with  the  diagnosis  of  pulmonary  abscess 
which  may  be  next  considered.  This  disease  may  begin  acutely  and 
without  any  hint  of  a  cause.  Blood  may  be  raised,  as  in  the  present 
case,  and  as  there  are  no  typical  signs  of  abscess,  we  cannot  quarrel 


i'ig. 


151;. 


Chest  signs  in  Case  311.     Histor}-;  sexen  ihus'  tough;   l)icK)(l\'  sjiuta. 


COUGH  595 

with  those  which  this  patient  shows.  Abscess  may  exist  with  almost  any 
combination  of  signs  and  without  any  signs  at  all. 

Nevertheless,  abscess  of  the  lungs,  arising  in  this  way  without  any 
known  cause  and  without  lesions  in  other  organs,  is  distinctly  rare  and 
the  character  of  the  sputa  is  not  at  all  typical.  One  expects  a  larger 
amount  of  pus  and  a  foul  odor. 

Acute  tuberculosis  cannot  be  excluded.  We  very  rarely  observe 
so  rapid  a  progress  in  tuberculous  disease,  and  the  negati\e  examina- 
tions of  sputa  are  of  considerable  though  not  of  decisi\e  importance. 
Most  cases  of  tuberculosis  beginning  with  hemoptysis  present  no  physical 
signs  at  all  within  the  first  two  or  three  weeks.  Accordingly,  the  ordinary 
course  of  affairs  is  as  follows:  The  patient  is  much  alarmed  by  the 
hemoptysis,  and  soon  calls  upon  a  physician  for  examination  of  the 
lungs.  This  examination  reveals  nothing  whatever.  The  tempera- 
ture is  normal,  the  blood-spitting  already  beginning  to  seem  ancient 
history  as  the  patient  now  feels  perfectly  well.  The  doctor  allows  his 
wish  to  be  the  father  of  his  hope,  and,  humoring  the  patient's  urgent 
desire  to  be  told  that  he  is  not  tuberculous,  gi\es  a  clean  bill  of  health 
and  surmises  that  the  l)lood  came  from  the  throat. 

Thus  a  golden  opportunity  is  lost,  and  the  patient  is  not  treated  for 
tuberculosis  until  the  more  obvious  signs  make  their  appearance  some 
months  later. 

in  the  present  case  there  is  nothing  that  we  can  do  but  persist  in  the 
sputum  examinations.  P>ither  tubercle  bacilli  will  appear  or  the  s])utum 
will  become  foul  and  take  on  the  other  characteristics  of  abscess. 

Outcome.^Only  on  the  fourth  examination — July  2d — were  tuber- 
cle bacilli  discovered.  The  [)aticnt  went  home  July  23d  considerably 
worse. 

T  take  this  opportunity  of  enumerating  and  discussing  brietly  the 
causes  of  hemoplysls.  Leaving  on  one  side  the  cases  in  which  only 
slight  streaks  or  fragments  of  blood  a])i)ear,  mixed  with  mu(()])urulent 
sputa,  and  also*  the  cases  in  which  blood,  obviously  deri\ed  from  the 
nasal  cavities,  is  ex])ectorated,  we  may  group  practically  all  the  cases  of 
hemoptysis  occurring  in  tem])erate  climates  under  the  following  three 
headings: 

[a)  Hemoptysis  due  to  tuberculosis. 

(//)  TIemo()t\sis  due  to  jjulmonarv  infarct,  usually  froni  mitral 
disease. 

(r)   Hemoptysis  from  ])ulmonar\-  abscess  inon  tubcrculousV 

The  last  two  groups  can  usuall\"  be  recognized  with  ease  by  the 
lustory  and  the  attending  ])h}sical  signs,  cardiac  or  pulmonar} .      J^rar- 


596 


DIFFERENTIAL  DIAGNOSIS 


tically  all  the  cases  of  hemoptysis  which  we  puzzle  over  are  later  ex- 
plained as  tuberculosis  or  else  remain  wholly  unexplained.  In  the 
unexplained  group  should  ])e  placed  those  traditionally  charged  up  to 
vicarious  menstruation,  to  hysteria,  and  other  mythical  causes. 

In  hemorrhagic  diseases,  such  as  purpura,  scurvy,  hemophilia, 
leukemia,  and  in  the  hemorrhagic  forms  of  the  exanthemata,  we  may 
have  blood-spitting,  but  diagnostic  puzzles  rarely  arise  in  these  diseases. 
Occasionally  a  case  of  uremia  obeys  the  mandate  of  nature  to  lower 
blood -pressure  by  any  and  all  methods,  so  that  pulmonary  hemorrhage, 
instead  of  the  ordinary  uremic  nose-bleed,  occurs.  There  could  be  no 
difficulty  in  recognizing  the  source  of  such  a  hemorrhage  unless  we 
omitted  to  study  the  heart  and  kidneys. 

In  many  cases  a  patient  is  alarmed  by  the  expectoration  of  blood 
which  the  physician  sees,  at  his  first  examination,  to  come  from  a  spong}' 
gum.  In  various  forms  of  stomatitis  the  patient  may  awake  in  the 
morning  to  find  a  blood-stain  on  the  pillow.  This  often  excites 
great  alarm,  but  the  most  casual  examination  of  the  mouth  should 
make  clear  the  source  of  the  bleeding.  Nocturnal  epilepsy,  however, 
should  also  be  remembered  in  such  a  case,  as  the  patient  may  be  himself 
quite  unaware  of  the  fit. 

Summing  up  this  discussion,  I  wish  to  emphasize  the  point  that  there 
is  hit  one  important  cause  of  obscure  hemoptysis,  viz.,  tuberculosis. 
If  the  source  c^f  a  ijulmonary  hemorrhage  is  not  made  clear  b}-  the 
examination  of  the  heart,  lungs,  gums,  and  nasophar}'nx,  and  if  it  is 
not  obviously  the  expression  of  some  infectious  or  constitutional  malady, 
it  is  in  all  probability  the  first  sign  of  phthisis.  I  do  not  deny  that  the 
causes  of  hemoptysis  are  numerous,  but  I  assert  that  the  causes  of 
genuinely  obscure  hemoptysis  in  temperate  climates  may  be  reduced  to 
one — pulmonary  tuberculosis.  I  may  refer  in  this  connection  to  the 
careful  study  of  F.  T.  Lord,^  in  which  it  is  demonstrated  that  in  the  great 
majority  of  cases  in  which  a  young  person  has  a  pulmonary  hemorrhage, 
recovers  at  once,  and  remains  well  for  the  rest  of  his  life,  postmortem 
examination  ])ro\es  tlie  bleeding  to  have  ])cen  due  to  tuberculosis  which 
healed  without  ever  ])roducing  further  symptoms. 

Diagnosis. — Pneumonic  phthisis. 

Case  312 

A  Canadian  ])rakeman,  twenty-seven  years  old,  was  jammed  Octo])cr 
31,  1907,  between  two  freight-cars  and  sustained  severe  contusions 
o\er  the  sacrum  and  left  thigh.     The  day  after  tlie  injury  he  had  a  se\ere 

1  Eoston  '\\v<].  and  Surg.  J'>ur.,  iooq,  vol.  cl.xi,  ji.  571. 


COUGH 


597 


chill;  another  occurred  while  in  the  ambulance  on  his  way  to  the  hospital, 
November  9th. 

For  the  past  ten  days,  while  in  the  surgical  wards,  he  has  had  cough 
and  continued  fever. 

Signs  of  solidification  were  found  at  last  near  the  angle  of  the  right 
scapula,  associated  with  a  good  deal  of  pain  in  that  side.  There  was  no 
dyspnea  at  any  time. 

When  seen  November  9th  the  white  cells  were  18,600.  The  ])atient's 
a])pearance  distinctly  suggested  phthisis,  but  repeated  examinations 
of  the  sputa  showed  no  tubercle  bacilli,  and  by  the  seventeenth  of  Novem- 


I'ig.  lOo. — Chart  of  case  31^. 


])cr  the  lung  signs  had  nearly  cleared  up,  thougli  rough  l)rcathing  and 
a  few  rales  were  still  heard  in  the  upper  left  lung. 

(^n  the  t\ycntieth,  there  was  dulncss  and  diminished  rcs])irati()n 
over  a  small  area  at  tlic  right  base.  A  needle  was  introduced  lierc  and 
])enetrated  thick,  liard  pleura  into  a])])arcnlly  normal  lung.  Soon  after 
tins  all  signs  (Hsa])pcared.  The  ])atient  was  al)le  to  go  home  on  iVv 
twenty-second,  entirely  ^\•ell. 

Discussion.-  it  is  natural  to  ask  at  llic  outset  whether  this  patientV 
symptoms  may  be  due  to  trauma;  so  se\-ere  an  accident  miglit  ea>il\' 
have  wounded  the  lunLT.  But  the  facts  seem  to  be  against  thi-  hypothe- 
sis. Ap])arently,  his  eliest  was  not  injured,  and  if  we  take  the  record 
on  its  face  \alue,  this  is  conclusixe.     At  the  i)ostmortem  tal)le,  howex'er, 


598  DIFFERENTIAL  DIAGNOSIS 

one  sometimes  sees  strange  revelations  in  cases  of  this  kind.  Fractured 
ribs  and  fractured  pelvis,  wholly  unsuspected  during  life,  I  have  seen 
demonstrated  postmortem  to  the  great  chagrin  of  all  concerned. 

It  is  difficult  to  suggest  in  the  prLated  record  the  strongly  tuberculous 
appearance  of  this  patient.  Any  one  in  the  habit  of  judging  by  facies 
and  the  general  look  of  the  patient  could  hardly  have  doubted  that  he 
was  phthisical.  If  one  adopted  this  hypothesis,  one  would  ha\e  to  say 
that  the  tuberculous  process  was  "lighted  up"  by  the  accident.  We 
have  good  reason  to  believe  that  a  patient's  general  power  of  resistance 
may  be  notably  diminished  by  such  an  accident  as  this,  so  that  he  becomes 
much  more  subject  to  infectious  disease  of  any  kind. 

Doubtless  this  idea  has  been  overworked  in  the  innumerable  suits 
for  damages  brought  against  steam  and  electric-car  roads  by  persons 
who  have  been  injured.  The  lawyer  for  the  plaintiff  can  always  succeed 
in  finding  some  doctor  who  will  swear  that  the  pulmonary  tuberculosis 
from  which  the  patient  now  suffers  in  an  ad^•anced  form  did  not  exist 
before  the  accident  and  must  have  been  produced  by  it.  But  without 
believing  that  anything  of  this  kind  often  happens,  one  must  admit 
its  possibility. 

In  the  present  case  we  must  confess  that  the  signs  are  quite  compati- 
ble with  tuberculosis,  though  by  no  means  typical  of  it.  Further  light 
can  be  ol^tained  only  by  the  results  of  repeated  sputum  examination  and 
by  the  cutaneous  tuberculin  test. 

Pleural  effusion  was  seriously  considered  here,  as  is  indicated  by  the 
fact  that  the  chest  was  punctured.  The  question,  "Have  we  fluid  or 
solid  in  this  chest?"  is  much  more  frequently  a  difficult  one  than  text- 
books would  lead  us  to  suppose.  A  small  effusion  at  the  base  of  the 
limg  may  so  compress  and  condense  the  pulmonary  tissue  abo\-e  it  that 
all  the  signs  of  solidification  are  present.  This  is  equally  true  in  dropsi- 
cal efi"usions  due  to  heart  disease  and  associated  with  edema  of  the 
lung  itself.     I  ha\e  known  many  such  cases  mistaken  for  pneumonia. 

In  view  of  the  outcome  of  the  case,  it  seems  more  than  probable 
that  the  whole  affair  represented  that  type  of  pneumonia  known  as 
"traumatic"  or  "surgical,"  and,  due  to  that  very  lowering  of  resistance 
by  traumatism  which  T  have  hinted  above,  is  often  falsely  lugged  in  to 
explain  a  long-standing  phthisis.  Doubtless  it  is  because  we  are  so 
familiar  with  the  fact  that  trauma  can  cause  pneumonia  by  favoring 
infection  that  we  in\oke  the  same  theor}-  quite  unjustifiably  in  tubercu- 
losis. 

Many  cases  of  "traumatic  pneumonia"  haA'c  much  more  insidious 
onsets  than  this,  not  only  without  dyspnea,  but  without  pain  or  cough, 


Fig.  i6i.— Signs  demonstrated  in  Case  313.     Complaint:  twenty  years'  "winter  cough. 


COUGH  599 

and  sometimes  without  fever.  The  latter  is  especially  apt  to  occur  in 
elderly  jjersons  and  remains  wholly  undiscovered  unless  routine  jjhvsical 
examination,  perjormed  as  a  sort  of  daily  house-cleaning,  brings  the 
disease  to  light. 

Diagnosis. — Traumatic  pneumonia. 

Case  313 

A  granite-cutter  of  sixty-fi\e  entered  the  hospital  February  17,  1908. 
His  family  history  and  past  history  were  excellent.  He  has  had  a  winter 
cough  for  twenty-years,  to  which  he  has  grown  so  used  that  he  thinks 
little  of  it;  but  for  six  weeks  his  accustomed  ''bronchitis''  has  been 
somewhat  worse  than  usual,  and  for  the  last  three  weeks  he  has  done 
but  little  work.  He  has  distress  after  each  meal,  and  abdominal  pain 
when  he  coughs  hard.  During  the  night  he  has  to  pass  water  every  hour, 
and  it  burns  him.  For  many  years  he  has  had  cramps  in  his  legs.  He 
says  they  are  most  troublesome  at  the  time  of  the  new  moon,  and  last 
through  the  first  quarter.  When  young,  he  weighed  175  pounds;  now  he 
weighs  123,  but  he  Sciys  he  has  lost  no  weight  of  late  years. 

The  })atient's  face  is  pitted  with  small-i)ox;  eyes  show  complete 
arcus  senilis  on  both  sides.  His  pupils  are  small  and  irregular,  the 
right  larger  than  the  left.     Both  react  to  light  and  distance. 

The  heart-sounds  are  somewhat  indistinct,  h\i\.  a  careful  examina- 
tion of  the  organ  shows  nothing  else  of  importance. 

The  blood-pressure  is  135  mm.  Hg.  The  arteries  are  palpable  and 
tortuous.  The  condition  of  his  lungs  is  shown  in  the  accompanying 
diagram.  Temperature,  blood,  and  urine  are  normal.  Underneath 
the  right  rib  margin  there  is  a  dull,  resistant,  firm  mass,  whicli  shifts 
little,  if  at  all,  with  respiration.  When  examined  in  a  warm  bath,  this 
tumor  disa])pears,  but  there  is  still  more  resistance  in  the  muscles 
of  that  region  than  elsewhere.  The  s])utum  is  \cry  profuse  and 
purulent.     The  ])atient  seems  weak  and  sleej)s  much  of  the  time. 

Discussion. — Cough  without  fc\cr  is  usually  of  no  great  im])ortance, 
especially  in  a  person  who  has  had  it  e\ery  winter  for  twenty  years. 
I'nder  these  conditions  it  is  natural  to  assume  it  an  old  man's  bnmchiec- 
tasis  with  a  more  recent  (possibly  inlluenzal)  infection  of  the  ca\itics. 
I'he  physical  signs  are  by  no  means  typical  of  this  condition  l-.err.  but 
they  will  do  in  case  the  si)uta  pro\-es  negatixc  and  no  other  good  reason 
for  the  cough  can  l)e  adduced. 

/;/  men  of  this  age  it  is  often  di/fuult  to  (]istiiio;nisli  ''  </  hcort  toui^Ji  " 
from  •'  ii  luiii^  coui:;!!.'^  (^irdiac-  weakness  favors  stasi>  in  the  lung>,  witli 
malnutrition  and   increased  susceiitibilitv  to  infection.     (  >n   the  other 


6oO  DIFFERENTIAL    DIAGNOSIS 

hand,  any  infection  of  the  bronchial  tract  leads  to  increased  work  for 
the  heart  and  thus  perhaps  to  cardiac  stasis.  This  patient  apparently 
has  arteriosclerosis  (palpable  and  tortuous  arteries),  and  his  heart- 
sounds  are  said  to  be  feeble.  But,  on  the  whole,  this  does  not  seem 
to  me  enough  to  make  us  consider  the  heart  seriously  as  a  cause  for  his 
cough. 

It  is  of  the  greatest  importance  to  remember  that  tuberculosis  may 
at  any  time  become  ingrafted  upon  the  lungs  of  a  patient  who  has 
suffered  for  many  years  from  nothing  more  serious  than  a  winter  cough. 
The  only  safe  plan  is  to  assume  each  time  that  one  sees  such  a  patient 
that  he  may  ha^^e  contracted  tuberculosis  recently,  and  to  test  this  pos- 
sibility by  repeated  examinations  of  the  sputa  as  well  as  by  a  temperature 
chart  and  a  study  of  the  pulmonary  signs.  In  the  statistics  of  Dr. 
Cleaveland  Floyd,  already  referred  to,  this  point  is  well  illustrated. 

Outcome. — On  the  third  examination,  tubercle  bacilli  were  found  in 
the  sputum. 

Diagnosis. — Phthisis. 

Case  314 

A  widow  of  thirty-five  entered  the  hospital  July  30,  1907.  Her 
husband  died  of  hemorrhage  from  the  lungs.  Her  family  history  is 
excellent.  She  had  pneumonia  six  years  ago,  in  the  Portland,  Maine, 
Hospital.  Since  the  birth  of  her  last  child,  three  years  ago,  she  has 
had  no  menstruation.  For  a  year  she  has  been  coughing  and  raising 
much  phlegm,  but  never  any  blood.  Three  weeks  ago  she  began  to 
cough  less,  but  has  been  much  "choked  up"  and  has  felt  very  weak. 
She  has  a  splendid  appetite  and  rarely  vomits.  Her  bowels  are  usually 
regular,  ])ut  she  passes  water  very  frequently,  both  day  and  night. 
She  siiys  she  once  weighed  200;  at  entrance  she  weighed  86.  She  says 
she  has  not  an  ache  or  a  pain,  and  complains  at  present  only  of  great 
general  weakness. 

On  examination  the  patient  is  found  to  be  emaciated,  the  skin 
dry  and  rough,  the  ])U])ils  irregular,  neither  reacting  to  light,  the  right 
larger  than  the  left.  The  heart  and  lungs  show  nothing  abnormal. 
The  abdomen  is  full,  resistant  in  the  u])per  half,  soft  and  tympanitic 
below.  The  H\cr  dulness  extends  from  the  sixth  rib  to  the  uml)ilicus, 
and  the  edge  of  the  organ  is  easily  felt  there.  The  white  cells  arc  4200; 
hemoglobin,  70  per  cent.  The  urine  contains  no  albumin  and  no  casts; 
si)ecihc  gravity,  1025;  it  contains  considerable  sugar.  On  the  fourth 
of  August  there  was  a  posit i\e  Widal  reaction,  a])solute  loss  of  motility, 
and  agglutination  in  one  hour  in  dilutions  of  i :  10  and  i :  50.     On  this 


COUGH  6oi 

date  there  were  many  fine,  moist  rales  at  the  base  of  each  lung;  a  small 
abscess  formed  at  the  top  of  the  right  little  finger.  It  was  opened  and 
a  pure  culture  of  staphylococcus  obtained.  The  sputum  was  repeatedly 
examined,  with  negative  results. 

On  August  8th  there  was  sudden  severe  pain  in  the  hypogastrium, 
with  a  falling  temperature,  a  rising  pulse,  and  increasing  abdominal 
distention.     All  symptoms  disappeared  after  two  hours. 

By  the  thirteenth  she  was  much  worse,  very  toxic,  noisy  and 
slightly  delirious,  with  muscular  tremor,  veins  bloated,  rales  growing 
more  numerous,  and  abdomen  more  distended.  The  diacetic  acid  which 
was  ])resent  in  the  urine  at  entrance  had  now  disappeared,  and  the  sugar 
had  fallen  to  2  per  cent. 

On  the  fourteenth  of  September  a  patch  of  bronchovesicular  rcs])ira- 
tion  with  cre])itant  rales  was  heard  in  the  right  axilla,  and  there  was 
slight  external  strabismus.  She  died  on  the  fifteenth,  the  diagnosis 
being  typhoid  fever,  diabetes  mellitus,  bronchopneumonia. 

At  autopsy  there  was  found  miliary  tuberculosis  of  the  lungs,  spleen, 
and  kidneys,  fatty  liver — no  evidence  whatever  of  typhoid.  The  patient 
had  stated  positi\-ely  that  she  had  ne\er  had  typhoid  fever. 

Discussion. — I  did  not  see  this  case  during  life,  and  I  have  no 
reason  to  belie\e  that  my  diagnosis  would  have  been  any  nearer  correct 
than  tliat  which  was  made.  Everybody  was  "bowled  over"  by  the 
W'idal  reaction,  and  assumed  that  the  case  was  one  of  ty]>hoid  fever. 
Looking  back  now  from  the  standpoint  of  the  autopsy,  it  is  worth  while 
to  consider  by  what  signs  we  might  have  been  warned  against  the  mistake 
which  we  made. 

01)\iously,  we  were  dealing  with  a  case  of  diabetes  and  not  merely 
with  a  sym])tomatic  glycosuria.  The  long-standing  weakness  and 
emaciation,  despite  a  splendid  appetite,  |)oint  to  this  conclusion.  But 
dial)ctes  is  ver\'  seldom  associated  with  typhoid  infection.  I  have  not 
been  ai)le  to  find  any  such  case  in  the  records  of  the  jMassachusetts 
General  Hospital,  though  Ourschmann  has  observed  such. 

It  is  notorious  that  tlicre  is  another  infectious  disease  wliicli  diabetics 
are  especially  ])rone  to  catch — \i/.,  tuberculosis.  Of  this,  there  is  little 
evidence  in  the  present  case,  yet  it  should  l)e  noted  that  the  patient  ha< 
l)een  coughing  and  expectorating  for  a  }ear,  and  that  tlie  ])ulnK)nary 
signs,  although  not  at  present  characteristic,  are  conipatil)le  witli  tuber 
culosis.  When  the  strabismus  appeared  in  the  last  days  of  tlu'  patit-nt'< 
life,  the  suggestion  of  tul)ercul<^sis  became  inevital)le.  befort'  that  the 
repeated  negati\e  examinations  of  the  sputa  tlirew  us  off  the  track,  and 
the  lung  signs  were  inter])rete(l  as  a  t}])l-i()id  bronchitis. 


6o2  DIFFERENTIAL  DIAGNOSIS 

As  I  review  the  results  of  autopsy  experience  in  diabetes  and  recall 
the  number  of  mistakes,  more  or  less  similar  to  that  made  in  the  present 
case,  I  feel  inclined  to  formulate  the  rule  that  any  pulmonary  signs 
(obviously  not  those  of  pneumonia)  occurring  in  a  diabetic  should  be 
assumed  to  be  due  to  tuberculosis,  especially  if  the  patient  is  in  an  ad- 
vanced stage  of  this  disease. 

The  Widal  reaction  remains  a  mystery,  and  furnishes  an  example 
of  the  dangers  attendant  upon  our  modern  habit  of  placing  almost 
exclusive  reliance  on  signs  of  this  kind  in  diagnosis.  If  this  case  had 
occurred  prior  to  1896,  it  is  probable  that  the  mistake  would  not  have 
been  made.  We  should  have  turned  more  attention  upon  the  past 
history  and  the  present  signs,  as  seen  in  the  light  of  our  general  knowl- 
edge of  the  complications  usually  occurring  in  diabetes. 

Diagnosis. — Miliary  tuberculosis  and  diabetes. 

Case  315 

A  married  woman  of  thirty-eight  was  first  seen  April  i,  1907.  She 
was  never  sick  until  seven  years  ago,  when  she  had  a  sore  on  the  genitals 
and  in  her  throat.     At  that  time  her  hair  came  out. 

Two  years  ago  she  had  an  operation  upon  her  breast-bone  at  the 
Carney  Hospital.  For  two  years  she  has  had  severe  headaches,  with 
"fits  and  faint  spells."  These  last  sometimes  seem  to  be  brought  on  by 
anger  or  excitement. 

In  December,  1906,  she  ga^■e  birth  to  a  child,  which  died  three  days 
later  at  the  Infants'  Hospital  and  was  said  to  have  had  syphilis. 

For  the  past  three  months  she  has  had  a  painful  cough,  with  night- 
sweats  and  thick  yellow  sputum.  She  is  weak,  dyspneic,  constipated, 
eats  and  sleeps  poorly,  has  many  headaches,  and  faints  when  she  gets 
angry. 

On  examination  the  patient  is  obese  and  shows  enlarged  glands  in  the 
neck,  axillae,  and  groins.  The  inner  third  of  the  right  clavicle  is  missing. 
An  old  operation  scar  occupies  its  site.  On  cough,  the  lung  projects 
through  the  hole  thus  left.  The  heart  and  peripheral  blood-vessels  show 
nothing  abnormal.  Over  an  area  extending  from  the  right  apex  to  the 
third  rib  in  front  and  to  the  scapula  behind,  expiration  and  inspiration 
are  very  noisy  and  strident.  There  are  occasional  crackling  rales  in 
this  area.  Elsewhere  the  lungs  are  negative.  The  sputum  shows  many 
intracellular  intlucnza  bacilli,  a  few  pncumococci,  no  tubercle  bacilli. 

A  letter  to  the  Carney  Hospital  showed  that  the  lump  excised 
from  the  clavicle,  which  before  operation  had  been  taken  to  be  tubercu- 
losis, showed  gumma  when  examined  histologically. 


COUGH 


603 


It  was  also  learned  that  the  patient  had  been  eight  months  in  the 
Worcester  Insane  Asylum  some  years  ago. 

Tuberculin,  10  milligrams,  was  injected,  with  negative  results. 
(For  temperature  see  the  accompanying  chart,  Fig.  162.) 

The  patient  was  given  mercur)';  also  iodid  of  potash  in  doses  increased 
from  10  to  100  grains  three  times  a  day.  By  this  treatment,  symptoms 
and  signs  very  markedly  improved,  so  that  by  the  eighteenth  of  April 
she  was  able  to  leave  the  hospital. 

The  physical  signs  at  this  time 
consisted  of  bronchovesicular  breath- 
ing and  a  few  medium  rales  at  the 
right  apex. 

X-ray  report  by  Dr.  Walter  Dodd : 

"Apices. — ^Both  present  hazy  ap- 
pearance. Left  more  marked  than 
right.  At  base  of  the  right  lung 
there  was  a  dense  shadow^  observed 
which  started  about  i  inch  from 
median  line  at  level  of  sixth  space. 
Shadow  was  deep  seated. 

Diaphragm.  —  Excursion  on  left 
side  normal.  Could  not  see  diaph- 
ragm on  right  side.  When  patient 
coughed  the  shadow  at  its  base  moved 
u})ward  about  i  inch  and  receded 
immediately." 

Discussion. — It  was  clear  enough  that  this  patient  was  suffering 
mainly  from  syphilis,  l)ut  what  of  the  pulmonar}-  conditions?  Tuber- 
culosis, as  is  well  known,  often  complicates  syphilis,  owing  to  the  diminu- 
tion of  resisting  [)ower  brought  about  by  the  syphilis.  Ordinar}-  t}])es 
of  bronchitis,  due  to  the  inlluenza  bacillus  or  other  organism,  arc  also  of 
frcfjuent  occurrence  in  sy{)hilitics.  There  are  no  ])insical  signs  or  clinical 
features  characteristic  of  ])ulmonary  syphilis,  so  that  the  diagnosis  can 
never  ])e  made  with  any  confidence. 

Fx])cricnce  seems  to  me  to  show  that  it  is  safe  to  assume  ]Hilmonary 
complications  of  this  kind  tol^edueto  svphih's,  pro\i(led,  of  cour>e.  lliat 
we  are  con\M'nce(l  by  sputum  examination  or  otherwise  that  tlie  case  is  not 
one  of  tu])crculosis.  It  was  shown  some  vears  ago  by  Dr.  K.  d.  jane- 
way  that  ])atients  who  ha\-e  fe\er.  night-sweats,  and  pulmonar}-  >ign> 
like  those  ordinarily  seen  in  ])luhisis  mav  prom])th-  reeo\er  under  anti- 
svphilitic  treatment,  after  residence  in  a  sanatorium  for  tulxrculosis  hiis 


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Fig.  162. — Chart  of  case  315. 


6o4  DIFFERENTIAL  DIAGNOSIS 

failed  to  benefit  them  at  all.  It  seems,  therefore,  the  wiser  course  to 
give  every  syphilitic  the  benefit  of  the  doubt,  and  treat  him  with  mercury 
and  potassium  iodid  while  we  continue  to  search  his  sputum  for  tubercle 
bacilli.  If  marked  and  rapid  improvement  takes  place  under  this 
treatment,  we  may  conjecture  that  we  ha\e  been  dealing  with  a  case  of 
pulmonary  syphilis,  but  as  the  pathologic  anatomy  of  that  disease  is 
practically  unknown,  it  is  difficult  to  make  any  positive  statement  on  the 
matter. 

A  point  of  great  interest  in  this  case  is  the  patient's  habit  of  fainting 
when  she  gets  angry.  Ordinarily,  one  would  call  attention  to  such  a 
symptom  as  indicating  a  hysteric  basis  for  any  other  complaints  which 
the  patient  might  express.  In  this  case  we  have  reason  to  believe 
that  organic  brain  disease  of  syphilitic  origin  is  present.  Yet  the  patient 
faints  when  she  gets  angry.  It  may  be  that  a  closer  psychologic  study 
of  the  case  would  show  that  the  fit  of  anger — like  the  fits  of  running 
which  immediately  precede  some  epileptic  attacks — is  the  first  symptom, 
not  the  cause,  of  the  subsequent  loss  of  consciousness.  In  anger  we  are 
only  partly  ourselves;  in  fainting  we  cease  to  be  ourselves  at  all. 

Diagnosis. — Syphilitic  disease  of  the  lung. 

Case  316 

A  gardener  sixty-one  years  old,  with  an  excellent  family  history, 
entered  the  hospital  June  24,  1908.  He  states  that  he  had  dropsy 
three  years  ago,  while  at  the  Boston  City  Hospital. 

Five  months  ago  he  caught  a  bad  cold,  and  has  had  a  troublesome 
cough,  with  profuse  sputa,  dyspnea,  and  j^oor  appetite  ever  since. 
For  three  months  he  has  had  orthopnea.  The  cough  often  keei)s  him 
awake. 

On  examination  he  was  found  to  be  emaciated,  orthopneic,  markedly 
cyanotic,  and  brcatliing  with  much  difficulty;  the  rate  was  from  40  to 
50  a  minute.  The  lungs  showed  many  coarse  bubljling  rales  on  both 
sides.  There  was  very  slight  dulncss  and  harsh  breathing  alcove 
and  below  the  riglit  cla\icle  in  front,  also  slight  dulness  and  ])roIonged 
low-])itclied  respiration  at  the  right  apex  Ijehind.  There  \\-as  slight  general 
abdominal  tenderness,  and  the  edge  of  the  liver  could  be  felt  i.\  inches 
below  the  ribs.  On  percussion,  the  upper  border  v;as  at  the  sixth  rib. 
(For  temperature,  see  the  accompan}-ing  chart.  Fig.  163.) 

The  white  cells  at  entrance  were  2().qoo;  the  urine,  sp,  gr.  looq 
to  10 14,  30  ounces  in  twenty-four  hours,  with  a  slight  trace  of  albumin, 
many  hyaline  and  coarse  granular  casts.  The  heart's  impulse  and  dulness 
were  felt  in  the  fiftli  sjjace,  inside  the  nipple-line.     A  systolic  mumiur 


COUGH 


605 


was  audible  at  the  apex,  and  the  pulmonic  second  sound  was  accentu- 
ated. The  first  apex  sound  was  very  loud  and  sharp.  The  arteries  were 
palpable  and  tortuous,  with  a  lateral  excursion  in  the  brachials. 

Discussion. — At  this  patient's  age,  with  the  evidences  of  cardiac 
and  vascular  disease  furnished  by  the  physical  examination,  and  in  xiew 
of  the  history  of  dropsy  three  years  previously,  it 
would  be  natural  to  assume  at  the  outset  that  the 
pulmonary  signs  are  due  to  stasis  and    insufficient 
heart  action. 

Against  this  idea,  however,  is  the  presence  of 
fever  and  leukocytosis,  neither  of  which  should  be 
produced  by  the  degenerative,  non-infectious  type  of 
heart  trouble  which  we  expect  in  people  of  this  age. 
The  acute  vegetative  types  of  endocarditis  and  the 
myocardial  infections  which  might  produce  fever 
and  leukocytosis  along  with  pulmonary  stasis  in  a 
younger  patient,  are  rarely  seen  at  sixty-one  unless 
as  terminal  infections.  The  present  illness,  however, 
has  been  going  on  for  five  months,  and  cannot  be 
called  terminal. 

We  arc  apt  to  forget  the  possibility  of  tubercu- 
losis in  people  who  have  managed  to  worry  through 
sixty  years  of  life  without  acquiring  it,  but  recent 
statistics  give  us  no  excuse  for  this  form  of  absent- 
mindedness,  and  warn  us  to  search  the  sputum  of 
every-  patient  who  has  any  cough,  whatever  his  age,  especially  when 
the  pulmonary  signs  seem  to  be  most  marked  at  the  apex  of  the  lung 
involved. 

Outcome. — The  sputa  showed  a  few  tubercle  bacilli,  though  it  had 
in  other  respects  the  characteristics  of  ])ulmonary  abscess  and  was  at 
times  excessively  foul.  The  patient  lost  ground  rapidly  after  entering 
the  hospital,  and  died  on  June  30th. 

Autopsy  showed  tuljcrculosis  of  the  lungs,  chronic  interstitial  ne- 
phritis, hy])ertro])hy  and  dilatation  of  the  heart,  tubercular  ulcers  of  the 
intestine,  and  hy])crnepliroma. 

Diagnosis. — See  last  paragraph. 


Fig.    163. — Chart 
case  316. 


Case  317 

.'\  weaver  of  twenty-four  was  seen  August  20,  1Q07.     He  bad  "stom- 
ach tr()ul)lc"  three  or  four  years  ago.     He  has  otherwise  l)een  well. 
A  week  ago  lie  l^egan  to  have  cough,  headache,  and,  after  two  days. 


6o6 


DIFFERENTIAL   DIAGNOSIS 


vomiting,  the  vomitus  containing  some  blood.     Three  days  ago  he  had 

a  chill,  pain  in  his  left  side,  loss  of  appetite,  insomnia,  and  constipation. 

He  has  been  in  bed  three  days. 

In  the  left  back,  close  to  the  spine  of  the  scapula,  are  heard  harsh 

respiration  and  a  few  fine  rales.     The  lungs  are  otherwise  negative. 

Palpation  of  the  abdomen  causes  severe  paroxysms  of  cough.  The 
blood  and  urine  are  negative.  (The  temperature 
is  as  seen  in  the  accompanying  chart.) 

The  next  morning  an  erythematous  eruption 
appeared  in  the  right  half  of  the  trunk,  arms, 
and  legs.  This  disappeared  after  calomel  ^ 
grain  every  half-hour  for  six  doses,  but  soon 
broke  out  again,  the  wheals  being,  however,  less 
numerous  the  second  time. 

On  the  twenty-fifth  of  August  the  upper  lip 
suddenly  became  much  swollen.  The  patient 
was  given  calcium  chlorid,  i  gram  three  times 
a  day,  Carlsbad  salts,  i  dram  three  times  a  day. 
On  the  twenty-sixth  he  was  practically  well. 

Discussion. — This  case  is  introduced  merely 
to  exemplify  one  of  the  unusual  manifestations 
of  urticaria.  I  have  previously  illustrated  the 
manifestations  of  urticarial  lesions  in  the  in- 
testinal tract.  (See  p.  73.)  In  the  present 
case  we  have  good   reason  to  believe   that  the 

bronchial  tree  was  the  seat  of  similar  lesions,  producing  patches  of  edema 

which  corresponded  to  the  signs  recorded  in  the  text. 

It  may  be  of  some  importance  not  to  forget  the  possibility  of  a  cough 

produced  in  this  way,  since  it  would  be  likely  to  yield  to  treatment  of 

the  same  type,  which,  in  some  cases,  is  found  to  be  effecti\'e  against  the 

cutaneous  wheals,  \'iz.,  catharsis  and  attention  to  diet. 
Diagnosis. — Internal  urticaria. 


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CHAPTER  XIX 

VOMITING 

The  act  of  vomiting  must  be  distinguished,  in  the  first  place,  from 
the  easy  and  more  or  less  habitual  regurgitation  of  the  normal  stomach- 
contents.  In  young  infants  this  presents  itself  as  the  familiar  phenomenon 
of  "spilling  over";  in  older  persons  it  is  often  a  matter  of  habit,  quite 
controllable  when  explained,  for,  curiously  enough,  there  are  those 
who  act  as  though  they  believed  that  the  stomach-contents  have  a 
divine  right  to  be  ejected  whenever  it  reaches  the  mouth.  A  little 
wholesome  advice  is  here  of  value. 

In  estimating  the  significance  of  vomiting  we  must  take  account  also 
of  the  patient's  temperament  and  of  some  other  habits  besides  that  just 
mentioned. 

(a)  There  are  people  who  have  learned  early  in  their  career  the 
trick  of  emptying  their  stomachs  on  slight  provocation,  with  or  without 

"the  aid  of  a  finger  in  the  throat.  To  such  people  the  slightest  gastric 
discomfort,  the  faintest  retrosternal  or  esophageal  irritation,  is  the 
signal  for  a  voluntary  emptying  of  the  stomach. 

(b)  At  the  other  extreme,  temperamentally  or  physiologically,  are 
those  who  may  have  gone  through  thirty  or  forty  years  of  life  without 
ever  tasting  the  experience  of  emesis.  In  a  person  of  this  type  we  may  be 
led  to  underestimate  the  importance  of  certain  symptoms  merely  because 
he  does  not  vomit. 

The  first  of  these  temperamental  extremes  is  especiallv  prominent 
in  the  gastric  neuroses,  and  when  the  existence  of  such  a  condition  is 
satisfactorily  established,  it  may  be  our  chief  duty  to  make  the  patient 
control  the  act.  This  can  be  accomplished  sometimes  by  a  simple 
explanation,,  sometimes  by  scolding,  sometimes  by  a  sort  of  mental 
counterirritation,  the  result  of  getting  the  patient  busy,  sometimes  by 
subpectoral  infusions  of  saline  solution,  which  the  patient  is  distinctly 
warned  must  continue  until  the  vomiting  stops.  To  break  a  habit  is 
the  main  object,  whatever  method  is  adopted.  I  have  known  an  ap- 
parently sensible  working-man  of  thirty-fi\-e  who  vomited  continuously 
until  four  months  had  elapsed,  and  55  pounds  of  his  weight  had  vanished, 
all  from  habit  a]one— a  habit  which  was  broken  without  much  difficulty 
in  the  course  of  a  week's  hospital  treatment  with  subpectoral  Infusions 
as  above  described. 

tiOH 


Causes  of  Vomiting 


1.  TOXEMIA  OF  PREGNANCY 

2.  "ACUTE  DYSPEPSIA" 

3.  ALCOHOLISM 

4.  SEA-SICKNESS 

5.  ONSET  OF  INFECTIOUS  DISEASES 

6.  POSTOPERATIVE  "SHOCK" 


CASES  TOO  MANY  AND  TOO  VAGUELY 
ENUMERABLE  FOR  GRAPHIC  REPRESEN- 
TATION. 


7.  GASTRIC        I 
NEUROSIS) 


8.  ACUTEAPPEN- 
DICITIS 


9.  CARDIAC      DIS- 
EASE 

10.  PEPTIC  ULCER 

11.  "GASTRITIS" 

12.  INTESTINAL 

OBSTRUC- 
TION 

13.  GASTRIC     ) 

CANCER  r 

14.  UREMIA 

15.  TABES 


2126 
1819 

1512 

309 

209 

167 

113 

45 
42 


r.oii 


VOMITING  6ll 

IMPORTANT  FACTORS  IN  THE  PRODUCTION  OF  VOMITING 

Three  prominent  elements  may  be  distinguished: 

(a)  Cerebral. 

(b)  Gastro-intestinal. 

(c)  Pharyngeal. 

Most  of  the  so-called  "reflex"  causes  of  vomiting  may  be  arranged 
without  much  violence  under  the  first  of  these  headings.  The  vomiting 
due  to  intense  pain,  that  induced  by  fright  and  other  strong  emotions  or 
by  fatigue,  can  probably  be  accounted  for  in  this  way.  The  majority 
of  toxic  varieties  of  vomiting  belong  in  the  same  group — e.  g.,  the  vomit- 
ing of  pregnancy,  cyclic  or  paroxysmal  vomiting,  and  that  accompanying 
migraine  and  hyperthyroidism. 

The  pharyngeal  factor  is  especially  important  in  the  morning  vomit- 
ing which  accompanies  many  cases  of  alcoholism,  but  which  is  very 
often  due  to  the  accompanying  pharyngitis  caused  by  smoking.  The 
patient  has  a  smoker's  throat,  which  he  rasps  and  scrapes  in  the 
clearing-out  process  when  he  wakes  in  the  morning.  The  pharyngeal 
irritation  finally  produces  emesis. 

Together  with  the  ordinary  gastric  causes  of  vomiting,  we  must 
remember  the  cases  in  w^hich  chronic  or  acute  intestinal  obstruction, 
with  or  without  peritonitis,  causes  the  stomach  to  empty  itself.  With 
many  of  the  intestinal  neoplasms  we  may  have  symptoms  very  closely 
simulating  those  of  cancer  of  the  stomach,  and  the  examination  of  the 
gastric  contents  and  functions  may  still  further  confuse  us,  since  gas- 
trcctasis,  hypomotility,  and  achlorhydria  may  be  found.  The  vomiting 
due  to  acute  appendicitis  or  to  strangulated  hernia  is  probably  of  the 
same  type. 

Finally,  we  may  mention  the  |)rolongc(l  attacks  of  emesis  accom- 
panying the  gastric  crisis  of  tabes  dorsalis,  the  exj)lanation  of  which  is  not 
as  yet  clear. 

Case  318 

An  Trish  bartender  of  forty  entered  the  hospital  January  i6,  igoS. 
He  had  catarrhal  jaundice  three  times  several  years  ago.  His  father 
(\m\  of  pleurisy.  The  ])aticnt  has  l)c'cn  a  very  hard  drinker,  consum- 
ing a  quart  of  whisky  and  17  large  beers  daily.  He  denies  venereal 
disease. 

I'or  many  years  he  lias  liad  stomacli  tToul)le.  He  vomits  early  in 
tlic  morning,  and  often  after  eating  anv  ordinary  food,  so  tliat  at  ])resent 
he  practically  ]i\es  on  li((uor.     He  cannot  renienil)er  to  Ikiac  been  intoxi- 


6l2  DIFFERENTIAL   DIAGNOSIS 

cated  so  that  he  could  not  do  his  work  and  take  care  of  himself.  His 
appetite  for  everything  but  liquor  is  very  poor. 

The  bowels  move  two  or  three  times  a  day. 

He  is  very  shortwinded,  and  for  two  weeks  has  noticed  scantiness 
of  his  urine,  enlargement  of  his  belly,  and  some  swelling  of  the  feet, 
"face,  legs,  and  hands.  A  week  ago  he  noticed  that  his  conjunctivae 
were  getting  yellow. 

Two  years  ago  he  weighed  195  pounds;   now  he  weighs  236. 

Physical  examination  showed  a  satin-like  skin;  no  jaundice;  feeble 
heart-sounds;  soft  and  apparently  normal  arteries;  blood-pressure, 
no.  There  was  nothing  abnormal  in  the  lungs.  He  had  an  enormous 
dome-shaped  abdomen,  with  slight  dulness  in  the  flanks,  showing 
perhaps  a  little  shift  with  change  of  position.  The  edge  of  the  liver 
not  felt,  though  there  is  dulness  for  2h  inches  below  the  right  costal 
margin.     There  was  slight  edema  of  both  legs. 

Discussion. — -This  seems  at  first  sight  an  obvious  case  of  alcohol- 
ism, but  on  closer  study  we  notice  that  the  heart-sounds  are  feeble, 
that  he  has  dyspnea,  that  the  face  and  extremities  are  edematous,  and 
that,  despite  persistent  vomiting,  there  has  been  a  marked  gain  in  body 
weight.  All  these  facts — and  especially  the  last  one — point  toward 
cardiac  disease,  which,  as  we  know,  is  frequently  a  cause  of  persistent 
vomiting. 

But  what  cardiac  disease  can  it  be?  There  is  no  evidence  of  a  valvular 
lesion  or  of  a  weakened  heart  due  to  kidney  trouble.  Chronic  fibrous 
myocarditis  was,  in  earlier  years,  a  favorite  diagnosis  in  cases  of  this 
kind,  but  the  autopsy  so  seldom  confirmed  it  that  many  of  us  are  grow- 
ing more  cautious.  Personally,  I  am  unwilling  to  make  a  diagnosis 
of  chronic  myocarditis  unless  there  is  convincing  evidence  of  arterio- 
sclerosis, and  unless  all  other  causes  of  cardiac  weakness  can  be  satis- 
factorily excluded.  But  there  is  no  evidence  here  of  arteriosclerosis, 
and  no  good  reason  for  the  heart  to  be  weak  merely  as  a  result  of  alcohol. 

In  any  such  patient  cirrhosis  must  be  considered,  especially  as  it 
might  help  to  explain  the  persistent  vomiting.  Cirrhosis  is  always  a 
difficult  disease  to  exclude,  since  we  know  that  it  usually  exists  for  years 
before  it  produces  any  symptoms.  All  we  can  say  in  a  case  like  this  is 
that  we  have  no  positive  evidence  of  it,  such  as  ascites,  enlargement  or 
shrinkage  of  the  liver,  hematemesis. 

Of  course,  the  gastric  functions  must  be  more  thoroughly  investigated 
if  the  patient  does  not  ]jrom])tly  yield  to  treatment  based  on  some  other 
hypothesis.  But  after  this  survey  of  the  case  we  have  obtained,  as  it  seems 
to  me,  so  little  ])ositive  evidence  of  any  disease  other  than  alcoholism 


VOMITING  613 

that  the  first  experiment  to  be  tried — all  treatment  is  an  experiment — 
is  an  anti-alcoholic  regime.  If  that  fails,  the  next  step  should  be  to 
pass  a  stomach-tube  and  examine  the  physical  and  chemical  functions 
of  the  stomach;  next,  if  that  proves  negative,  to  try  the  effect  of  cardiac 
stimulation  preceded  by  depletion. 

Outcome. — Alcohol  was  withdrawn  entirely  at  entrance.  The 
patient  was  given  a  diet  of  liquids  and  soft  solids,  with  10  minims  of  the 
tincture  of  capsicum  before  each  meal,  an  ounce  of  magnesium  sulphate 
early  each  morning,  and  2  drams  of  ])araldehyd  every  afternoon.  In 
four  days  he  was  able  to  eat  without  vomiting  and  sleep  without  medicine. 
In  a  week  he  felt  perfectly  well,  but  was  much  surprised  to  disco\er  that 
he  could  exist  without  rum. 

Diagnosis. — Alcoholism. 

Case  319 

A  housemaid  of  twenty-four  entered  the  hospital  October  11,  1906. 
She  had  always  been  well  except  for  habitual  constipation,  the  bowels 
moving  once  in  from  t\vo  to  six  days.  She  has  taken  no  breakfast  for 
some  weeks  and  has  occasionally  vomited.  A  week  ago  the  f)atient 
was  married.     Her  last  menstruation  was  August  14th. 

At  3  o'clock  this  afternoon  she  began  to  vomit,  and  soon  after  had 
a  sudden  sharp  abdominal  pain,  with  faintness,  and  in  the  course  of 
the  day  six  loose  movements  of  the  bowels. 

Examination  was  negati\'e  save  for  slight  dulness  in  the  right  flank, 
slight  tenderness  of  the  epigastrium  and  along  the  right  side.  .At 
McBurney's  point  tenderness  was  very  marked  on  dec])  |)ressurc,  and 
there  was  spasm  o\'er  this  area. 

Vaginal  examination  shows  much  tenderness  high  up  on  the  right  side, 
but  no  mass. 

The  white  cells  were  16,800;  urine,  negative;  temjjcrature.  ])u]se, 
and  respiration  normal.     The  breasts  were  somewhat  large. 

Discussion. — The  vomiting  here  might  well  be  due  to  ])rcgnancy, 
but  no  one  could  make  any  such  statement  without  any  further  evi- 
dence than  is  furnished  by  the  ])hysical  signs  here  reported.  If  the 
histor}-  is  taken  as  correct. — that  is,  if  her  last  menstruation  was  August 
14th, — there  is  hardly  time  enough  for  the  (le\elopment  of  an  ecto[)ic 
gestation,  which  should,  moreo\er.  show  more  definite  signs  on  \aginal 
examination  or  more  characteristic  e\idence  of  hemorrhage. 

Patients  of  this  type  not  infrec|uently  take  large  (lo^es  of  irritating 
cathartic  medicine  in  the  atteni])!  to  i)r(Kluce  a  miscarriage.  The 
loose  moxements  of  the  bowels  and  the  xomitinu  niiuht  be  tluis  accc)untc(i 


6l4  DIFFERENTIAL  DIAGNOSIS 

for.  No  history  of  this  kind,  however,  could  be  elicited,  and  the  patient 
seemed  to  be  telling  the  truth. 

The  patient's  habitual  consti])ation  might  account  for  a  good  deal 
of  vomiting,  but  hardly  for  such  an  acute  attack  or  for  tenderness  and 
spasm  in  the  right  iliac  fossa. 

One  always  hesitates  to  make  a  diagnosis  of  appendicitis  when  the 
temperature  and  pulse  are  normal  and  when  there  has  been  no  pre\ious 
attack.  Nevertheless,  in  the  presence  of  very  marked  tenderness,  with 
spasm  at  McBurney's  point  and  leukocytosis,  appendicitis  seems  the 
most  reasonable  diagnosis.  A  pyosalpinx  might  produce  very  much 
the  same  physical  signs,  but  would  probably  show  a  mass  or  induration 
by  vagina,  and  would  not,  in  all  j^robability,  come  on  so  acutely  without 
any  other  or  ]:)revious  symptoms. 

Outcome. — Operation  October  12th  showed  acute  appendicitis. 
There  were  no  old  adhesions. 

Diagnosis. — Appendicitis. 

Case  320 

A  married  woman  of  fifty-three  with  an  excellent  family  history 
entered  the  hospital  September  28,  1907.  She  has  been  strong  and 
healthy  all  her  life,  with  the  exception  of  a  double  inguinal  hernia,  for 
which  she  was  successfully  operated  upon  in  May,  1907.  Since  child- 
hood she  has  been  in  the  habit  of  passing  water  once  at  night  after  bed- 
time. 

About  a  year  ago  she  began  to  have  attacks  of  vomiting,  in  which 
she  was  unable  to  retain  any  kind  of  food,  the  vomitus  consisting  at  first 
of  the  food  ];re\'iously  eaten,  unmixed  with  mucus  or  Ijlood.  Last 
fall  the  vomiting  ceased  altogether,  and  she  was  in  the  IMassachusetts 
General  Hospital  for  a  Colles'  fracture.  During  her  stay  here  nothing 
abnormal  was  noted  in  the  digestive  functions,  but  after  her  return 
home  vomiting  began  again,  and  has  gradually  grown  more  frequent 
up  to  the  present  time.  She  has  vomited  every  day  through  the  past 
summer — sometimes  three  times  a  day.  At  no  time  has  there  been  any 
j)ain  except  after  eating  a  large  amount,  and  then  only  slight  distress. 
I'here  have  Ijecn  no  eructations  of  gas  and  no  swelling  of  any  })art 
of  the  abdomen,  though  tlie  e])igastrium  lias  been  somewhat  tender 
on  jjressure  for  two  montlis. 

Fifteen  months  ago  she  weighed  124  ])0unds;  four  months  ago,  116: 
now  she  weighs  100  pounds.  Her  bowels  have  gradually  become 
consti])ated.  She  has  noticed  no  jaundice.  She  has  never  considered 
herself  ner\T)us. 


VOMITING 


615 


The  temperature  and  pulse  were  as  seen  in  the  accompanying  chart. 
The  patient  was  poorly  nourished  and  pale,  though  her  hemoglobin 
was  75  per  cent,  and  the  white  cells  were  7300.  The  heart  and  lungs 
showed  nothing  abnormal.  In  the  upper  abdomen  was  a  hard,  tender 
mass,  descending  with  respiration.     (See  Figs.  165  and  166.) 

Physical  examination,  including  the  urine,  was  otherwise  negati\e. 
The  stools  showed  no  occult  blood.     Vaginal  and  rectal  examinations 
were  negative.     Through  the  stomach-tube  only  13  ounces  of  water 
could  be  introduced  without  extreme  pain,  retch 
ing,  and  struggling.     There  was  no  food  in  the 
fasting  stomach.      After  an   Ewald  test-meal  the 
gastric  contents  showed  no  free  acid  of  any  kind. 
The  benzidin   test   for   blood  was   positive;    the 
wash-water    used    for    lavage    returned    slightly 
blood-stained. 

Discussion. — The  early  part  of  this  history 
reminds  us  of  a  gastric  neurosis,  because  one 
isolated  symptom — vomiting — seems  to  make  up 
the  whole  clinical  picture.  When  any  single  symp- 
tom, such  as  vomiting,  gaseous  eructation,  diarrhea, 
or  constipation  persists  over  a  considerable  period 
of  time  with  little  or  no  background  of  other 
interconnected  symptoms,  it  usually  turns  out 
that  we  are  dealing  with  a  neurosis — that  is,  with 
a  morbid  habit.  We  can  make  such  a  statement, 
however,  only  when  we  have  exhausted  all  the 
resources  of  physical  diagnosis  without  finding 
any  evidence  of  organic  disease. 

We  cannot  attribute  the  vomiting  to  constipation  or  to  the  exhaus- 
tion produced  by  any  constitutional  or  infectious  disease,  since  we 
have  no  evidence  of  these  conditions.  A  consultant  suggested  the  ])os- 
sibility  of  cerebral  tumor,  and  the  fundus  oculi  was  examined  with 
this  possibility  in  \iew.  Neither  there  nor  elsewhere,  ho\\eN'er,  could 
we  find  any  support  for  the  assum])tion  of  Ijrain  disease. 

As  soon  as  the  epigastric  mass  was  clearly  made  out  and  tlie  ])Os- 
sibility  of  its  being  due  to  a  fecal  accumulation  was  excluded  l)y  free 
catharsis,  it  began  to  be  ])reUy  e\"idenl  that  the  ^•omiting  was  due  either 
to  ulcer  or  cancer  of  the  stomach.  This  ])ecame  still  more  cerUiin 
when  it  was  recognized  that  the  ca])acit}-  of  the  stomach  \\as  diminished 
and  its  secretion  of  hydrochloric  acid  al)()lished.  Tt  remained  to  deride 
the  question:    cancer  or  ulcer?      Such  a  tumor  is  often  produced  l)y 


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case  320. 


6l6  DIFFERENTIAL  DIAGNOSIS 

a  perigastric  exudate  around  an  old  ulcer.  But  the  histor}-  is  dis- 
tinctly against  ulcer  and  in  favor  of  cancer.  Ulcers  seldom  begin  in 
persons  who  have  lived  to  fifty-two  years  without  gastric  disturbances. 
They  are  hardly  ever  characterized  by  vomiting  without  pain,  and  in 
the  earlier  stages  of  their  course  there  are  usually  long  periods  of  free- 
dom from  symptoms  and  marked  relief  (even  during  the  acute  stages 
of  the  disease)  immediately  after  the  taking  of  food. 

One  of  the  things  that  made  it  rather  difficult  to  realize  that  cancer 
was  really  the  most  reasonable  diagnosis  in  this  case  was  the  entire 
absence  of  pain.  This,  however,  is  by  no  means  unprecedented.  A 
number  of  similar  cases  have  been  recorded. 

Outcome. — Dr.  Maurice  Richardson  made  a  diagnosis  of  cancer 
of  the  lesser  curvature,  without  obstruction  of  the  pylorus,  and  advised 
against  operation  of  any  kind. 

Under  liquid  and  soft  solid  diet,  with  small  doses  of  calomel  and 
magnesium  sulphate,  hydrochloric  acid,  20  minims  after  food,  the 
patient  ceased  vomiting  on  October  4th  and  felt  a  great  deal  better. 

Diagnosis. — Gastric  cancer. 

Case  321 

A  married  woman  of  thirty-fi\'e  entered  the  hospital  ]March  24,  1908. 
She  lost  one  brother  by  phthisis  in  the  previous  December.  She  has 
had  two  children  and  no  miscarriages.  Her  youngest  child  is  seven 
years  of  age. 

Three  years  ago  she  was  in  St.  Elizabeth's  Hospital  for  ten  weeks 
on  account  of  stomach  trouble;  dilatation  and  curetting  of  the  uterus 
were  done. 

Five  years  ago  she  weighed  144  pounds.     A  week  ago  she  weighed  1 10. 

During  these  past  five  years  she  has  been  having  attacks  of  vomiting, 
at  first  only  before  each  menstrual  period,  later  at  other  times.  Her 
vomitus  was  watery  and  contained  undigested  food,  but  never  any 
food  eaten  twenty-four  hours  before.  She  has  not  been  free  from 
vomiting  for  more  than  two  weeks  since  1903.  The  vomiting  relieves 
sharjj  epigastric  pain,  which  is  usually  worse  after  eating.  In  1905 
she  vomited  two  cupfuls  of  dark  blood.  On  a  milk  diet  this  ceased, 
but  returned  eleven  weeks  later.  In  November,  1907,  she  again 
vomited  blood  and  had  e])igastric  pain  and  tenderness.  She  was  con- 
fined to  bed  a  week  at  that  time;  she  has  not  vomited  since,  but  still 
has  epigastric  pain  and  tenderness,  worse  after  food.  Her  appetite 
is  poor;  the  bowels  move  only  with  enema ta.  She  has  no  headache. 
Her  eye-sight  is  good. 


VOMITING  617 

Physical  examination  is  negative  save  for  a  blowing  systolic  murmur 
limited  to  a  small  area  near  the  apex  of  the  heart.  There  is  slight 
epigastric  tenderness,  but  no  spasm.  The  right  kidney  is  easilv  felt, 
its  lower  pole  being  on  the  level  of  the  navel. 

After  a  test-meal  the  gastric  contents  showed  free  HCl,  0.14  j^er 
cent.;  total  acidity,  .25  per  cent.;  guaiac  test,  negative.  The  stools  were 
also  free  from  blood. 

The  patient  did  excellently  well  on  a  diet  of  milk  and  eggs,  fol- 
lowing roughly  the  formula  of  Lenhartz. 

On  the  second  of  May  she  seemed  well  and  was  allowed  to  go 
home. 

The  patient  returned  to  the  hospital  August  3,  1908,  stating  that, 
two  weeks  after  leaving  the  hospital  before,  she  had  an  attack  of  vomit- 
ing with  the  menstrual  period,  and  this  vomiting  had  continued  for 
the  two  subsequent  periods,  though  she  was  perfectly  well  between 
them.  The  vomiting  seemed  to  be  entirely  inde}:»endent  of  the  taking 
of  food.  The  vomitus  contained  no  blood.  At  the  time  of  these  attacks 
she  had  a  good  deal  of  epigastric  ])ain,  and  has  a  little  pain  all  the  time, 
slightly  relieved  by  food  and  accompanied  by  gaseous  and  sour  eructa- 
tions.    She  sleeps  poorly,  on  account  of  nervousness,  she  believes. 

Physical  examination  shows  marked  pallor,  the  red  cells,  3,050.000; 
hemoglobin,  45  percent.  Two  normoblasts,  also  considerable  achromia 
and  deformities,  were  seen  while  making  the  differential  count  of  200 
white  cells.  The  polynuclear  cells  were  82  per  cent.  The  urine  was 
negative. 

The  stools  showed  a  slight  but  constant  reaction  to  guaiac. 

Stomach-tube  examination  showed  essentially  the  same  condition  a?  in 
the  ])rcvious  s[)ring.  There  were  no  fasting  contents.  The  patient  did 
excellently  well  on  a  diet  of  crackers  and  milk. 

Discussion. — In  marked  contrast  to  the  ])revious  case,  the  stomach 
trouble  is  here  of  long  duration — live  years  or  more — and  occurs  in  a 
young  woman.  Tn  the  early  stages  of  the  disease,  and  to  a  certain 
extent  throughout,  the  ])ain  seems  to  be  connected  with  menstruation, 
as  if  it  were  a  ''reflex"  nervous  distur])ance  associated  with  the  ner\"()us 
tension  of  that  ])eriod.  The  relief  of  ])ain  by  \omiting  and  the  attack 
of  hematemesis  in  Tgo5  still  further  support  the  diagnosis  of  peptic 
ulcer  or  hy])Ochlorhy(lria,  which  had  l)ccn  alreadv  suggested  b}  the 
previous  history. 

In  August,  jQoS,  her  symptoms  still  suggest  c'liiet]y  pe]ilii'  ulcer, 
but  we  ha\e  now  one  sym])tom  not  easily  accounted  for  on  tliat  h}  ]ioihe- 
sis,  \iz.,  the  \erv  marked   anemia.       There   ha>    been    no  e\idence  of 


6l8  DIFFERENTIAL   DIAGNOSIS 

hemorrhage  for  three  years,  and  peptic  ulcer  does  not  produce  anemia 
unless  there  is  sharp  bleeding. 

It  is  not  likely  to  produce  anemia  by  oozing  or  discharging  blood 
in  small  quantities.  The  marrow  readily  makes  up  these  losses.  Neither 
is  it  likely  that  a  large  amount  of  blood  might  have  been  poured  out 
at  one  time  and  discharged  wholly  by  rectum  without  the  patient  being 
aware  of  it.  Such  rectal  hemorrhages  produce  so  much  weakness  and 
thirst  that  the  patient  is  usually  made  aware  that  something  has  hap- 
pened. 

Nevertheless,  it  must  be  admitted  that  everything  else  in  the  case 
save  this  one  fact — an  unexplained  anemia — points  to  chronic  ulcer, 
and  perhaps  the  anemia  alone  is  not  of  sufficient  diagnostic  significance 
to  outbalance  the  other  indications  which  favor  ulcer.  But  since  the 
trouble  has  gone  on  so  long  and  recurs  so  frequently  under  dietetic 
treatment  it  seems  as  if  the  patient  should  be  given  the  benefit  of  an 
exploratory  laparotomy,  especially  as  there  is  at  least  a  possibilit}^  that 
the  anemia  may  be  due  to  something  more  serious — L  e.,  to  gastric 
cancer. 

Outcome. — August  14th  the  abdomen  was  opened.  A  cancerous 
mass  was  found  on  the  posterior  wall  of  the  stomach,  with  metastases 
in  the  omentum.  Gastro-enterostomy  was  done.  A  month  later  the 
patient  was  reported  as  eating  well,  sleeping  well,  and  gaining  in  weight. 

Diagnosis. — Gastric  cancer. 

Case  322 

A  widow  of  forty-five  entered  the  hospital  August  14,  1906.  She 
lost  her  husband  of  consumption  twelve  years  ago.  Sixteen  years  ago 
she  had  an  attack  similar  to  the  present  one,  which  was  cured  in  two 
weeks.  A  year  ago  she  had  another  attack,  and  was  in  the  hospital 
for  three  weeks  on  rectal  feeding,  during  w^hich  her  weight  fell  from 
137  to  117  pounds.  Since  then  she  has  been  dieting  carefully,  has  felt 
pretty  well,  and  has  not  been  troubled  by  indigestion. 

Nine  days  ago  she  was  suddenly  seized  with  sharp  abdominal  pain 
and  vomiting.  This  pain  has  recurred  frequently  since  that  time. 
It  is  relieved  by  vomiting,  1jut  shows  no  other  relation  to  food.  Occa- 
sionall}-  it  requires  morj)hin.  In  her  attack  of  sixteen  years  ago  she 
vomited  blood,  but  there  has  been  none  since.  For  the  past  three 
months  she  has  liad  occasional  attacks  of  diarrhea,  the  movements 
being  preceded  by  pain  and  often  containing  blood. 

For  the  past  two  days  she  has  Ijeen  fed  exclusively  by  the  rectum. 
Her  weight  is  now  120  ])ound>. 


VOMITING  619 

On  examination  the  patient  is  very  well  nourished,  but  rather  neuras- 
thenic. There  is  a  soft  systolic  murmur  at  the  apex  of  the  heart.  The 
pulmonic  second  .sound  is  larger  than  the  aortic  second.  The  heart 
shows  no  enlargement.  The  lungs  are  negati\e.  The  right  side  of  the 
abdomen  is  held  rather  rigid,  owing  to  marked  tenderness,  greatest  in 
the  middle  quadrant. 

Physical  examination,  including  the  vagina  and  rectum,  is  otherwise 
negative,  as  are  the  blood,  urine,  temperature,  y^ulsc,  and  respiration. 

The  patient  in  the  early  days  of  her  treatment  seemed  markedly 
neurasthenic,  but  this  ceased  after  the  cessation  of  the  menstrual  flow, 
and  she  was  able  to  take  solid  food  in  moderate  amounts  for  three  days. 

After  this  the  patient  began  to  vomit  a  great  deal.  Nutrient  enemata 
caused  much  distress  and  seemed  to  aggravate  the  vomiting.  On  the 
fourth  day  she  was  able  to  take  some  champagne  and  some  albumin- 
^\■ater  flavored  with  sherry,  without  any  vomiting.  The  \omitus  was 
found  to  be  strongly  acid,  and  consisted  mostly  of  clear  mucus. 

Sodium  bicarbonate  relieved  her  pain  somewhat,  but  it  ^\■as  ^•omited 
after  a  short  time.     Only  morphin  gave  relief. 

After  a  test-meal  the  stomach-contents  showed  an  abundance  of 
free  hydrochloric  acid  and  a  positive  guaiac  reaction.  The  stools  were 
foul  smelling,  dark,  and  bloody. 

On  the  twentieth  the  patient  comi)lained  a  great  deal  of  abdominal 
cramps.  The  stool  at  this  time  was  found  to  contain  much  fresh  blood 
and  a  considerable  amount  of  pus  and  mucus.  The  blood  showed: 
Red  cells,  3,676,000;   white  cells,  10,000;    hemoglobin,  65  })er  cent. 

The  stained  specimen  showed  nothing  remarkable  except  achromia. 
Further  study  of  the  stools  showed  that  they  contained  almost  no  fecal 
matter. 

The  sul^scquent  examination  of  the  abdomen  showed  on  the  right 
side,  low  down,  something  which  felt  like  hard  lumps,  which,  however, 
disaj)pearcd  with  the  rumbling  of  gas.  The  ca])acity  of  the  lower  Ijowel 
was  measured  with  warm  water,  and  only  a  ]nnt  could  Ijc  introduced. 
There  seemed  to  be  no  distention  of  the  transverse  colon,  l)ut  the  region 
of  the  ascending  colon  \\as  ])ersistently  distended.  The  attempt  to 
introduce  more  than  a  pint  of  water  In-  rectum  was  repeatedly  unsuc- 
cessful. 

Discussion. — \\'e  see  occasionally  in  adults  those  unexphiined  at- 
tacks of  summer  diarrhea  and  vomiting  which  are  so  common  in  \'ounL: 
children;  but  we  do  not  expect  them  to  persist  for  nint>  (ia\>.  True, 
this  |)atient  is  ncurastlienic,  so  the  record  states,  and  that  might  account 
for  a  great  deal,  especially  as  the  attack  has  hapj)ened  to  occur  at  the 


620  DIFFERENTIAL   DIAGNOSIS 

menstrual  period.  During  the  earlier  days  of  her  treatment  we  ac- 
counted for  her  symptoms  in  this  way.  Among  the  other  possibilities 
considered  was  hypochlorhydria,  which  will  next  be  discussed. 

The  previous  attack  of  hematemesis  was  described  by  the  patient 
as  similar  to  the  present  trouble.  The  illness  of  1905  also  suggests 
hypochlorhydria  or  ulcer.  The  stomach-contents  now  show  a  positive 
guaiac  reaction  and  a  large  amount  of  free  hydrochloric  acid.  There 
is  also  blood  in  the  stools.  When  all  these  facts  came  to  light,  we  were 
inclined  to  switch  over  from  the  idea  of  gastric  neurosis  to  that  of  peptic 
ulcer,  all  the  more  so  when  it  turned  out  that  sodium  bicarbonate 
relieved  her  pain. 

It  was  not  until  the  second  week  of  treatment  that  the  intestinal 
symptoms  began  to  seem  more  important,  especially  as  we  could  find  no 
good  cause  for  the  well-marked  secondary  anemia.  There  had  been  no 
recent  hemorrhage  to  account  for  it,  and  it  did  not  appear  that  the 
diarrhea  had  lasted  long  enough  in  any  of  her  previous  attacks  or  in 
the  present  one  to  produce  so  much  anemia.  It  was,  however,  the  con- 
dition of  the  stools,  especially  the  presence  of  pus,  and  the  remarkably 
small  amount  of  fecal  matter  which  led  us  further  to  investigate  the 
possibility  of  intestinal  neoplasm.  When  we  found  that,  on  two  separate 
occasions,  not  more  than  a  pint  of  water  could  be  introduced  into  the 
rectum,  even  when  slowly  and  carefully  given,  the  suspicion  of  intestinal 
neoplasm  low  down  in  the  colon  became  such  that  operation  was  ad- 
vised. 

Outcome. — The  abdomen  was  opened  on  the  twenty-seventh  of 
August,  revealing  a  cancer  of  the  sigmoid. 

This  case  and  several  others  which  I  saw  about  the  same  time  were 
\ery  instructive  to  me  because  I  had  never  been  warned  of  the  pos- 
sibility and  the  danger  of  getting  our  attention  so  focused  on  the  gastric 
manifestations  of  what  turns  out  to  be  intestinal  obstruction  that  the 
]jossibility  of  the  latter  does  not  occur  to  us.  If  once  we  get  a  false  start, 
we  may  find  a  good  deal  to  confirm  us  in  our  mistake.  For  example, 
in  a  recent  case,  which  turned  out,  like  the  present  one,  to  be  due  to 
a  cancer  of  the  sigmoid,  everything  seemed  at  first  to  point  to  the  stomach. 
A  stomach-tuljc  was  passed,  and  proved  the  presence  of  gastric  enlarge- 
ment and  the  absence  of  free  hydrochloric  acid.  The  patient  was  fifty 
years  of  age,  and  had  never  had  any  gastric  symptoms  before  the  present 
year.  All  these  facts  seemed  to  point  so  strongly  to  gastric  cancer  that 
we  neglected  to  make  a  sufficiently  careful  examination  of  the  abdomen 
or  to  put  well-directed  questions  concerning  bowel  movements,  the 
exact  location  of  pain,  and  intestinal  noise. 


VOMITING  621 

"Gastric  neurosis"  is  the  diagnosis  on  the  record  of  another  case 
of  causeless  vomiting  and  diarrhea  in  an  elderly  woman,  who  was 
promptly  relieved  in  the  hospital  by  a  few  days  of  diet  and  quiet 
(1908).  Dr.  E.  A.  Codman  insisted  that  intestinal  cancer  was  present, 
though  no  tumor  was  felt.  The  patient  remained  perfectly  well  for 
several  months,  but  Dr.  Codman's  diagnosis  was  ultimately  ^■erified. 

Diagnosis. — Cancer  of  the  sigmoid. 

Case  323 

A  waitress  of  nineteen,  born  in  Maryland,  entered  the  hospital 
January  14,  1907.  She  has  a  good  family  history  and  past  history  ujj 
to  eighteen  months  ago,  when  she  began  to  lose  strength  and  to  have 
dizzy  spells,  especially  after  breakfast.  Her  appetite  continued  good, 
and  she  felt  in  other  rcs])ects  well  until  alx)ut  two  months  ago,  when  she 
began  to  liave  nausea,  coming  on  about  live  minutes  after  eating,  and 
relieved  at  the  end  of  about  an  hour  by  vomiting  the  food  just  taken, 
together  with  considerable  phlegm.  She  ne\er  vomits  except  after 
breakfast,  although  she  has  considerable  distress  after  the  other 
meals. 

She  has  worked  until  a  week  ago,  and  still  feels  well  enough  when 
her  stomach  is  empty.  She  gets  up  once  each  night  to  pass  water. 
She  has  noticed  a  somewhat  tender  spot  in  the  epigastrium.  P'or  three 
months  she  has  ])een  somewhat  pale  and  short  of  breath  on  exertion. 

On  examination  the  j)atient  was  found  to  be  pale.  There  was  a  faint 
systolic  murmur  in  tlie  pulmonar}-  area;  otherwise  the  chest  is  negative; 
likewise  the  abdomen  and  urine. 

The  blood  showed  red  cells,  4,012.000;  white,  6.S00;  hemoglobin, 
55  per  cent.  Differential  count  normal;  marked  achromia;  no  other 
changes. 

Discussion. — We  may  rule  out  without  further  consideration  the 
long  list  of  organic  diseases,  such  as  cancer,  tuberculosis,  and  brain 
tumor,  of  which  \omiting  is  a  symptom.  The  first  point  to  ])e  noticed 
on  the  ])ositi\"e  side  is  that  nausea  of  this  tyj)e,  Ihougli  not  of  this  dura- 
tion, is  often  seen  in  the  early  months  of  ])regnancy — a  ])()ssil)ilit\-  which 
should  never  be  forgotten  when  we  arc  dealing  with  obstinate  digestixe 
disturbances.  I  once  siiw  a  ])atient  who  had  been  for  some  weeks 
under  the  care  of  a  distinguished  s])eeialist  in  gastric  troubles,  whose 
treatment  made  it  evident  that  he  had  never  considered  the  lu^sibilit}' 
of  i)regnanc\',  though  the  ])atient  had,  during  the  period  of  hi>  tn-atnient, 
an  amenorrhea  and  all  the  other  usual  e\idences  of  earl\  preunancy. 
When  I  saw  lier  the  condition  was  (luite  ob\ious. 


622  DIFFERENTIAL   DIAGNOSIS 

Nothing  is  said  about  menstruation  in  this  case,  but  inquir)-  showed 
that  it  had  been  absent  for  the  past  three  months.  This  fact,  together 
with  the  stomach  trouble  and  a  certain  degree  of  bad  conscience,  had 
considerably  alarmed  the  patient.  It  was  found  on  examination,  how- 
ever, that  there  was  no  uterine  enlargement  and  none  of  the  other 
evidences  of  early  pregnancy. 

Many  cases  like  this  turn  out  on  careful  study  to  be  the  result  of 
the  disturbances  ])roduced  by  constipation.  There  was  nothing  in  the 
histor}',  however,  to  indicate  that  she  was  constipated.  The  testimony 
of  a  patient  is  not  always  reliable  on  this  px)int.  Fecal  movements 
mav  occur  daily,  and  yet  be  so  insufficient  in  amount  that  a  considerable 
accumulation  takes  place.  One  has  no  right  to  assume  this  unless 
physical  examination  or  the  inspection  of  the  stools  demonstrates  it. 

Some  eager  surgeons  would  consider  the  evidence  here  presented 
as  sufficient  for  a  diagnosis  of  peptic  ulcer  or  chronic  appendicitis,  but 
there  is  not  the  relief  by  food  so  characteristic  of  the  earlier  stages  of 
peptic  ulcer,  while  the  symptoms  are  too  continuous  and  include  too  little 
suffering  from  pain  to  gi\e  us  any  genuine  indication  of  chronic  appen- 
dicitis. 

But  for  the  abnormalities  of  the  blood-picture  one  would  here  be 
forced  to  say  that  physical  examination  is  negative,  a  conclusion  which 
lies  very  near  to  the  decision:  gastric  neurosis.  Is  that  slight  anomaly 
in  the  hemoglobin  percentage  and  in  the  stained  smear  sufficient 
to  account  for  so  much  gastric  disturbance?  Yes,  it  certainly  is,  if 
we  take  it  as  the  outward  and  visible  sign  of  a  more  extensi\'e  and 
less  comprehended  malady,  to  which  we  give  the  superficial  and  un- 
satisfactory name  of  chlorosis.  Experience  has  often  shown  that 
chlorosis  may  produce  vomiting  as  severe  as  that  complained  of  by  this 
girl,  and  in  the  absence  of  any  other  obvious  cause  one  should  plan 
treatment  upon  this  hypothesis. 

Outcome. — The  patient  was  put  to  bed  and  given  f  grain  calomel 
e\ery  fifteen  minutes  for  eight  doses,  followed  the  next  morning  by  i 
ounce  of  magnesium  sulphate.  Liquid  and  soft  solid  diet,  with  nux 
and  gentian  before  meals,  was  perfectly  well  borne.  The  patient 
had  no  vomiting,  no  gastric  symptoms  of  any  kind,  and  ])y  the  twenty- 
third  was  up  and  had  an  excellent  appetite,  although  her  blood  showed 
no  gain  whate\"er. 

(^n  the  tenth  of  Fel)ruary  the  patient  went  home  much  stronger 
and  better,  although  her  hemoglobin  was  only  70  per  cent. 

Diagnosis. — Chlorosis. 


VOMITING  623 


Case  324 


An  unoccupied  Irish  girl  of  nineteen,  of  good  family  and  past  his- 
tory, entered  the  hospital  June  7,  1908.  Five  weeks  ago  she  began 
to  have  abdominal  pain  and  frequent  vomiting.  The  pain  was  colickv 
and  not  localized.  It  seemed  to  have  no  relation  to  food,  and  had  onl\- 
occurred  three  or  four  times  in  the  past  five  weeks,  lasting  an  hour 
or  two.  Yet  since  the  pain  ceased  she  has  continued  to  vomit  almost 
daily  whether  she  eats  or  not.  Yesterday  she  vomited  live  times,  though 
she  took  only  milk.  The  vomitus  sometimes  consists  of  undigested 
food,  sometimes  of  a  yellowish  or  blackish  sour  fluid.  It  has  never 
been  red  or  brown.  The  vomiting  seems  to  have  no  relation  to  the 
time  or  the  character  of  food.     The  catamenia  are  regular. 

The  appetite  remains  fair,  the  bowels  constipated,  moving  e\ery 
day  or  two  by  enemata  only. 

On  examination  the  patient  is  obese,  ruddy.  There  is  slight  general 
tenderness  over  the  lower  abdomen,  with  some  ^■oluntary  spasm,  ]^re- 
venting  satisfactory  palpation. 

Physical  examination,  including  the  temperature,  pulse,  respira- 
tion, blood,  urine,  and  stools,  was  not  otherwise  remarkable,  though 
the  stools  were  found  to  contain  many  bismuth  crystals. 

Discussion. — A  diagnosis  seems  to  me  impossible  here  without  a 
therapeutic  test.  We  should  first  get  the  bowels  started  and  watch 
to  see  if  that  does  not  check  all  the  other  symptoms.  Suppose,  then, 
that  the  vomiting  still  continues,  and  we  are  still  unable  to  find  any 
physical  cause  for  it  despite  our  most  jminstaking  examination  of  tlie 
internal  viscera  and  despite  the  absence  of  an}'  discoverable  cause, 
such  as  morphin,  malaria,  or  starvation,  what  course  should  be  pursued? 

It  is  almost  inevitable  to  assume  that  the  case  must  represent  some 
ty])e  of  neurosis  and  to  ])lan  treatment  accordingly,  yet  this  is  never 
a  satisfactory  Ixisis  of  action  unless  we  can  o])tain  other  evidence  of 
neurotic  constitution  besides  the  vomiting  itself.  1  was  greath"  im- 
pressed, a  few  months  ago,  by  the  outcome  of  a  case  in  which,  owing 
to  the  negative  results  of  repeated  and  searching  examinations.  \\c 
made  the  diagnosis  of  gastric  neurosis  and  used  a  great  deal  of  moral 
suasion.  Yet  the  man  ])roceeded  to  die,  and  tlie  autopsy  (No.  2^14. 
iMassachusetls  General  Hosjjital  auto])sy  records)  showed  al)solutch 
no  cause  for  death.  1  do  not  believe  for  a  moment  that  our  cliagno>i^ 
was  right  here,  yet  it  would  be  ditTicult  to  a\-oi(l  niakinu:  the  >ame 
mistake  again. 

In  the  ])resent  case  we  acted  on  the  ])rinci])le  that  it  is  always  wise 


624 


DIFFERENTIAL   DIAGNOSIS 


to  remove  any  possible  cause  for  the  patient's  symptoms  before  com- 
mitting ourselves  absolutely  to  any  diagnosis.  The  result  is  shown 
by  the  outcome. 

Outcome. — As  soon  as  the  bowels  were  thoroughly  evacuated  by 
cascara,  olive  oil,  i  ounce  twice  a  day,  and  enema ta,  vomiting  ceased; 
and  within  a  week  the  patient  was  eating  ravenously  without  any  dis- 
tress or  nausea.  The  bowels  continued  to  be  very  sluggish.  She  was 
advised  to  eat  a  great  deal  of  green  vegetables  and  as  much  fat  as  she 
could  tolerate. 

Diagnosis. — Constipation  (neurosis  ?). 


Case  325 

A  housewife  of  thirty-eight,  of  good  family  history,  was  first  seen 
April  21,  1908.  She  had  pleurisy  six  years  ago  and  a  still-born  child  a 
year  ago,  since  when  she  has  been  nervous  and  troubled  with  indiges- 
tion. For  three  weeks  she  has  had  a  great  deal  of  indigestion,  accom- 
panied by  "smothering  feelings  around  the 
heart."  For  ten  days  she  has  vomited 
everything  taken  into  the  stomach,  averag- 
ing ten  attacks  in  twenty-four  hours.  E\-en 
water  is  rejected.  She  has  sometimes  vomited 
as  much  as  a  quart  of  undigested  food  and 
once  about  a  teaspoonful  of  bright  blood 
which  her  physician  said  came  from  her 
throat.  Her  indigestion  and  smothering  feel- 
ings are  worse  after  eating  and  are  relieved 
by  vomiting.  She  is  \-er}'  constipated  and 
belches  much  gas.  During  these  three  weeks 
there  has  been  palpitation  of  the  heart.  At 
the  beginning  of  this  spell,  ten  days  ago,  she 
also  had  numbness  of  the  right  leg  and  left 
arm  for  two  days. 

\M'ien  sixteen  years  old  she  had  swollen 
glands  in  the  neck,  which  discharged  for 
about  two  years. 

The  patient  is  oljcse,  the  right  pui)il  slightly  larger  than  the  left, 
both  reacting  normally.  There  are  four  small  irregular  scars  on  the 
left  side  of  the  neck. 

Tlie  heart's  aj)ex  is  in  the  fifth  space,  \  inch  outside  the  midclavicular 
line.     The  sounds  are  normal.     There  are  no  murmurs.     The  lungs 


Fig.    16S. — Chart    cf   case 

325- 


VOMITING  625 

and  abdomen  are  normal;  reflexes  are  normal.  The  stools  give  no 
reaction  to  guaiac. 

(For  temperature  see  Fig.  168.) 

Discussion. — An  essential  element  in  diagnosis  is  here  omitted: 
we  have  no  account  of  the  urine  or  of  the  blood- pressure,  although 
there  is  apparently  a  slight  cardiac  enlargement  which  mjght  suggest 
a  chronic  nephritis  as  the  cause  of  the  vomiting.  This  hypothesis, 
however,  was  at  once  upset  by  the  negative  result  of  urinalysis. 

Gastro-intestinal  troubles  of  the  type  here  recorded  are  not  infre- 
quently the  first  and  most  obscure  manifestations  of  a  tuberculous  infec- 
tion. It  is  vcT}'  probable  that  she  suffered  from  a  cervical  adenitis, 
tuberculous  in  origin,  when  she  was  sixteen.  The  history  of  a  dis- 
charge from  swollen  neck  glands  and  especially  the  duration  of  the 
discharge,  together  with  the  present  evidence  of  scars  in  the  neck,  leaves 
no  considerable  reason  for  doubt  upon  this  point.  If  she  is  correct  in 
supposing  that  she  had  pleurisy  eight  years  ago,  the  probability  of 
tuberculosis  still  lingering  somewhere  in  the  system  is  still  further  in- 
creased. 

I  do  not  think  it  is  possible  absolutely  to  exclude  tuberculosis  as  the 
cause  of  sym])toms  in  this  case,  and  I  am  aware  that  some  persons 
would  consider  the  variations  in  temperature  shown  in  the  accompany- 
ing chart  as  sufficient  to  constitute  additional  evidence  favoring  tuber- 
culosis. On  the  whole,  however,  it  seems  to  me  that  the  evidence  is 
insufficient.  A  very  large  number  of  ])aticnts,  demonstrably  not  tuber- 
culous, have  as  much  tcm])erature  as  this  chart  shows  o\\ing  to  any  of 
a  variety  of  causes.  Repeated  examinations  of  the  lungs  and  other 
viscera  revealed  absolutely  nothing.  The  patient's  nutrition  was 
excellent.  I  ver}-  much  doubt  whether  she  had  any  more  tuberculosis 
than  the  rest  of  us — /.  c,  whether  it  was  {present  in  any  active  form  or  was 
responsible  for  any  of  her  syni])toms. 

The  still-ljorn  cl.ild  cind  the  irregular  ])upils  compel  us  to  consider 
for  a  moriK-nt  the  (lucstion  of  s}])l.ilis,  but  neither  on  questicming  nor 
by  examining  the  sites  at  which  syphilis  most  often  leaves  e\idences 
of  itself  could  we  find  any  rciison  furtlu-r  to  entertain  this  susjncion. 

The    ])atient    presented    ni;iny    neurotic    characteristics    not    easilv 

to  be   described.     Whether   tliesc   v.ere   the   cause   of   tlie   constipation 

or  its  results  1  cannot  say;   the  (|uestion  seems  to  me  iisiK'Hy  iinan>\vera- 

ble  in  such  cases.     The  sensil)le  thing  to  do,  howexcr.  is  to  att;;ck  the 

syni])tom-complex  at  a.n\-  and  all  of  its  \ulnerable  point>.      I.et  u>  begin 

uith  the  constipation. 

Outcome. — The   patient   was  gi\en   a   high   oil    enema.    6   ounces, 
III 


626  DIFFEREMTIAL  DIAGNOSIS 

followed  by  a  suds  enema.  Her  gastric  distress  was  relieved  by  h  dram 
of  essence  of  peppermint.  She  was  given  fluid  extract  of  cascara  and 
the  enemata  continued  daily.  Under  this  treatment  the  patient  was 
able  to  take  liquid  and  soft  solid  diet  and  by  the  twenty-fifth  could  eat 
anything  with  relish. 

By  the  twenty -ninth  all  symptoms  had  disappeared,  although  the 
patient  still  felt  somewhat  weak. 

Diagnosis. — Constipation  (neurosis?). 

Case  326 

A  Canadian  bolt-maker  twenty-seven  years  old  entered  the  hospital 
October  14,  1907.  He  lost  one  sister  of  consumption  some  years  ago. 
His  mother  now  suffers  from  "asthma";  otherwise  his  family  history 
is  good,  and  he  himself  has  always  been  well,  save  that  for  the  past  five 
years  he  has  hawked  up  a  good  deal  of  yellow  material  from  his  throat. 
He  smokes  and  chews  five  cents'  worth  of  tobacco  a  day.  His  habits 
are  otherwise  good. 

Eight  days  ago,  while  at  work  and  in  his  usual  health,  he  became 
nauseated  and  vomited,  the  vomitus  consisting  of  the  food  last  eaten. 
He  kept  at  work  that  day  but  felt  wxak  and  has  not  tried  to  work  since 
then.  The  first  night  he  felt  feverish,  but  he  has  not  noticed  this  since 
that  time.  The  nausea  and  vomiting,  however,  have  continued  and 
have  been  especially  troublesome  in  the  morning.  He  has  no  severe 
pain,  but  a  slight  soreness  in  the  epigastrium,  rather  more  to  the  right 
than  to  the  left,  ascribed  by  him  to  retching.  There  has  been  no  chill 
and  no  cough.  His  bowels  have  been  rather  loose  for  the  last  two  days. 
He  has  not  been  jaundiced. 

On  examination  the  temperature,  pulse,  respiration,  and  blood  are 
all  normal.  The  urine  shows  a  very  slight  trace  of  bile,  and  on  careful 
examination  of  the  eyes  a  slight  yellowing  of  the  conjunctivas  over  the 
peripheral  portion  of  the  eyeball  is  discerned.  Near  the  iris  there  is  no 
yellowness. 

The  tonsils  are  slightly  enlarged  and  reddened.  The  heart  and  lungs 
show  nothing  abnormal.  The  abdomen  is  slightly  rigid  just  below 
the  right  costal  margin  and  there  is  some  tenderness  at  that  point.  No 
soreness  or  spasm  is  felt  elsewhere.  The  liver  dulness  extends  one  or 
two  fingerbreadths  below  the  costal  margin,  but  no  liver-edge  can  be 
felt. 

Discussion.— The  presenting  symptoms  are  vomiting  and  bile 
m  the  urine.  Whether  we  shall  call  the  condition  jaundice  depends 
upon  our  definition  of  this  word.     In  all  the  more  marked  cases  in 


VOMITING  627 

which  the  conjunctiva  is  stained  by  bile-pigment,  the  discoloration 
extends  not  only  over  the  deeper  and  less  easily  visible  portions  of  the 
sclera,  but  up  to  the  outer  border  of  the  iris.  In  milder  cases  there  is 
a  ring  of  white  or  bluish-white,  unstained  sclera  around  the  iris.  But 
if  the  yellow  coloration  outside  this  ring  is  well  marked,  we  do  not 
ordinarily  hesitate  to  call  it  jaundice.  The  doubtful  cases  arc  those 
in  which  it  is  only  by  drawing  back  the  eyelids  and  by  getting  the  patient 
to  turn  the  eye  as  far  as  possible  to  one  side  that  any  yellow  coloration 
can  be  seen.  In  most  of  these  cases  the  tint  is,  moreover,  a  very  pale 
one.  Our  hesitation  is  further  increased  because  we  find  so  many 
cases  of  this  type,  if  once  our  curiosity  is  aroused  to  look  for  them.  Never- 
theless, it  seems  to  me  that  the  only  defensible  course  is  to  use  the  word 
jaundice  whenever  any  degree  of  yellow  discoloration  is  \isible  in  the 
sclera. 

Proceeding  on  this  basis  we  may  say  that  the  case  under  considera- 
tion is  characterized  by  vomiting  and  jaundice  occurring  without  other 
notable  s}Tnptoms  in  a  workingman  of  twent\--seven.  Gall-stones 
are  unusual  at  this  age,  and  we  ha^■e  no  tenderness  or  palpable  mass 
in  the  region  of  the  gall-bladder,  no  e%idence  of  hepatic  enlargement, 
and  no  characteristic  biliary  colic.  Nothing,  indeed,  suggests  any 
local  trouble  except  the  slight  rigidity  below  the  right  costal  margin, 
and  we  have  no  fever  or  other  constitutional  manifestiition  of  infection 
in  the  biliary  tract. 

Under  these  conditions — i.  c,  when  jaundice  occurs  without  any 
ob^"ious  cause,  without  any  marked  toxemia  or  other  e^"idence  of  infec- 
tion, without  any  change  in  the  shape  or  the  size  of  the  lixcr,  and 
without  any  evidence  of  gall-stones— it  has  long  been  customary  to  make 
a  diagnosis  of  catarrhal  jaundice.  That  the  condition  so  named  often 
gi\cs  rise  to  vcr}-  persistent  nausea  with  or  without  vomiting  is  a  familiar 
fact.  I'hcrcforc,  although  we  do  not  know  wluit  we  mean  by  the  term 
"catarrlial  jaundice"  in  the  sense  of  understanding  its  pathology,  it 
is  reasonable  to  use  the  term  in  a  case  of  this  kind,  at  any  rate  as  long 
as  nothing  more  serious  ai)i)cars  in  sight.  If  the  jaundice  docs  not  go 
off  within  six  weeks,  we  begin  to  fear  that  something  more  im]iortant 
is  behind  it — viz.,  gall-stones  or  cancer.  During  those  six  weeks, 
therefore,  our  diagnosis  always  rests  on  shaky  foundations;  indeed, 
it  is  never  confirmed  until  the  j^atient  is  well. 

Since  examination  has  revealed  no  sufiicient  reason  to  fear  that  the 
vomiting  in  this  case  results  from  any  deeper  and  more  olxcure  le>i<>n 
of  the  gastro-intcstinal  tract,  kidnev.  heart,  or  brain,  catarrlial  jaundice 
seems  to  be  our  best  working-and-talking  hypotliesis. 


628  DIFFERENTIAL   DIAGNOSIS 

Outcome. — The  patient  was  given  a  diet  in  which  carbohydrates 
and  fat  were  considerably  restricted;  calomel,  ^  grain  every  fifteen 
minutes  until  ten  doses  were  taken,  followed  in  half  an  hour  by  |  ounce 
artificial  Carlsbad  salts,  and  each  morning  thereafter  by  30  grains 
of  sodium  phosphate  and  an  enema  of  plain  water  made  5  degrees 
cooler  each  day  up  to  the  limit  of  tolerance.  On  the  second  day  he 
was  given  dilute  muriatic  acid  5  minims,  with  i  dram  of  fluid  extract 
of  taraxacum  after  each  meal. 

By  the  twenty-fourth  the  jaundice  and  other  symptoms  had  practically 
disappeared. 

Diagnosis. — Catarrhal  jaundice. 

Case  327 

A  sewing  woman  of  thirty-six  entered  the  hospital  January  6,  1908. 
She  had  lost  one  sister  of  consumption  seven  years  ago.  Her  family 
history  is  otherwise  good.  The  patient  has  always  been  strong  and 
well  and  was  in  comfortable  circumstances  until  the  time  of  the  San 
Francisco  earthquake  in  April,  1907,  when  she  lost  everything.  In  the 
past  year,  though  working  very  hard  at  sewing,  she  has  been  unable 
to  earn  enough  to  give  herself  proper  food  and  lodging.  Her  men- 
struation has  always  been  regular  until  recently,  but  its  last  appearance 
was  two  months  ago. 

For  the  past  four  months  she  has  been  very  much  run  down  and  so 
nervous  that  she  has  not  been  able  to  work,  though  she  has  not  been 
constantly  in  bed  for  any  length  of  time.  She  was  in  a  hospital  during 
the  whole  of  July  and  August,  and  was  somewhat  better  after  her  stay 
there,  but  not  able  to  work. 

Up  to  two  weeks  ago  she  had  no  symptoms  except  weakness  and 
an  occasional  headache.  Two  weeks  ago  she  began  to  vomit  and  has 
continued  to  do  so  very  frequently  every  day  since,  rejecting  all  that 
she  eats  and  considerable  yellow  and  whitish  material  besides.  She 
has  seen  no  blood  in  the  vomitus  at  anv  time.  Her  abdomen  is  sore 
all  over,  but  there  is  no  pain  anywhere.  Since  the  vomiting  began 
the  bowels  have  moved  once  in  two  or  three  days.  She  has  no  head- 
ache. Her  eye-sight  is  good.  She  has  taken  only  cereals,  milk,  and 
water  for  the  past  two  weeks. 

There  is  a  faint  tremor  of  the  lips  and  hands;  well-marked  arterial 
pulsation  in  the  neck.  The  aortic  second  sound  is  accentuated.  There 
is  consideral)le  pigmentation  of  the  abdominal  wall  al)out  the  navel. 
The  urine  shows  a  strong  reaction  for  acetone  and  diacetic  acid;  the 
amount    averages    30    ounces    in  twenty-four    hours;    specific   gravit}-, 


VOMITING 


629 


from  1014  to  1017,  with  the  slightest  possible  trace  of  albumin,  a  few 
hyaline  casts  and  a  trace  of  sugar,  later  estimated  to  be  0.69  per  cent. 

Visceral  examination,  including  the  pelvis,  is  otherwise  negative. 
The  blood  shows  nothing  abnormal. 

Discussion. — As  we  review  the  results  of  physical  examination,  the 
first  point  worthy  of  note  is  the  tremor  of  the  lips  and  hands  and  the 
violent  arterial  pulsation  in  the  neck.  In  women  of  this  age  such  hints 
should  always  lead  us  to  examine  the  eyes  for  slight  degrees  of  exoph- 
thalmos, to  scrutinize  the  neck  for  unobserved  goiter,  and  to  count  the 
pulse  under  various  conditions — all  with  reference  to  a  possible  Graves' 
disease  (hyperthyroidism)  in  larval  form.  Such  a  search  was  here 
imdertaken,  but  was  fruitless. 

The  urine  contains  sugar  and  acetone  bodies.  Is  it  possible  that 
we  are  dealing  with  a  diabetes,  and  that  the  vomiting  is  due  to  that 
disease?    Against  it  we  may  range  the  following  e\idence: 

(a)  The  cardinal  symptoms  of  diabetes — thirst,  polyphagia,  poly- 
uria, and  emaciation — are  absent. 

(b)  The  amount  of  sugar  in  the  urine  is  very  small,  although  the  diet 
has  not  been  in  any  way  restricted. 

(c)  Severe  constitutional  manifestations — such  as  vomiting  and  head- 
ache— appear  in  diabetes  late  in  the  course  of  the  disease,  after  the  car- 
dinal symptoms  have  been  manifested  for  a  considerable  period. 

(d)  Acetonuria  is  very  common  as  a  result  of  severe  and  prolonged 
vomiting  from  any  cause. 

(e)  A  slight  glycosuria — such  as  that  here  present — is  not  at  all 
uncommon  in  persons  of  a  nervous  temperament  and  under  any  unusual 
])sychic  strain. 

There  seems,  therefore,  no  sufficient  reason  to  treat  this  jjatient  as 
a  diabetic.  But  if  we  are  to  disregard  the  acetonuria,  the  glycosuria, 
and  the  tremor  and  fmd  no  reason  for  supposing  them  to  ])oint  to  any 
organic  disease  which  might  account  for  the  vomiting,  there  seems 
to  be  nothing  left  but  that  old  and  much-overworked  hy])othesis — 
neurosis.  This  is  made  a  little  more  jjlausible  than  ordinary  in  the 
j)rcsent  case  because  the  j)atient's  circumstances,  the  nature  of  her  work, 
and  the  tragedy  through  which  she  passed  nine  months  before  are 
sucli  as  to  fa\or  the  development  of  a  nervous  breakdown.  There  >ecms, 
on  the  whole,  to  be  no  l)ettcr  l)asis  for  work  and  talk. 

Outcome. — The  ])atient  was  given  a  diet  of  milk,  one  third  lime- 
water,  4  ounces  every  two  hours.  The  bowels  were  moxcd  by  cnrmala. 
Witlu'n  twenty-four  hours  she  was  so  much  im])r()\e(l  that  she  could 
take  an  ordinarv  mixed  diet.     Tremblinir  and  nerxou.-nes^  markedlv 


630  DIFFERENTIAL  DIAGNOSIS 

lessened;  acetone,  diacetic  acid,  and  sugar  disappeared  within  three 
days  on  full  diet.  She  was  somewhat  sleepless,  but  was  helped  by  15 
grains  of  trional  for  two  nights,  after  which  she  slept  fairly  well  without 
any  hypnotic. 

On  the  eleventh  the  patient  was  allowed  to  sit  up  in  bed.  On  the 
fifteenth  she  tried  to  walk,  but  was  very  dizzy  and  weak.  On  the 
twentieth  she  was  able  to  walk,  and  thereafter  gained  rapidly. 

Diagnosis. — Exhaustion. 

Case  328 

A  musician  of  fifty  entered  the  hospital  August  4,  1906.  The  family 
history  and  past  history  are  good.  He  denies  alcohol  and  venereal 
disease. 

A  week  ago,  without  known  cause,  he  was  suddenly  seized  with 
colicky  epigastric  pain,  nausea,  and  vomiting.  Since  that  time  he 
has  vomited  everything  that  he  has  eaten.  There  has  been  soreness, 
but  no  marked  abdominal  pain,  and  no  blood  in  the  vomitus. 

He  gave  up  work  five  days  ago.  This  morning  he  began  to  hiccup 
and  has  continued  for  the  past  two  hours.  He  has  never  had  a  similar 
attack.  His  general  health  has  been  good.  During  the  first  four  days 
of  this  attack  he  had  diarrhea. 

On  examination  the  patient  is  thin  and  wiry.  His  pupils  are  slightly 
irregular  and  react  sluggishly.  There  is  no  lead-line.  The  glands 
in  the  neck,  axillas,  and  groins  are  palpable,  but  not  enlarged. 

The  chest  and  abdomen  show  nothing  abnormal,  although  there 
is  some  tenderness  in  the  lower  portion  of  the  abdomen  and  the  sharp 
edge  of  the  liver  is  palpable  on  deep  inspiration. 

The  knee-jerks  are  lively,  the  fundus  oculi  negative,  likewise  the 
blood  and  urine.  Within  a  couple  of  days  the  pain  was  gone,  the 
patient  ^■ery  hungry,  yet  he  \omited  when  solid  food  was  given  to  him. 

Discussion. — At  this  man's  age  the  sudden  occurrence  of  vomiting 
makes  us  think  first  of  all  of  cerebral  or  cardiorenal  disease,  but  we 
find  no  confirmation  of  this  idea  in  the  results  of  objective  investigation. 

Gall-stones  is  a  possibility  to  be  reckoned  with,  but  on  that  hy- 
pothesis it  is  hard  to  explain  why  the  vomiting  should  ha^■e  continued 
for  a  week  after  the  pain  has  ceased.  The  same  difficulty  confronts 
us  if  we  try  to  reason  that  chronic  appendicitis  or  nephrolithiasis  may 
have  produced  the  pain.  For  pej)tic  ulcer  in  the  stage  of  perforation 
the  local  manifestations  are  not  sufficiently  acute  and  definite;  for  any 
other  stage  in  the  course  of  this  disease  the  s}'mptoms  are  too  violent 
and  the  vomiting  too  continuous. 


VOMITING  631 

I  mention  the  phrase  ''ptomain  poisoning"  because  I  have  so  fre- 
quently heard  it  used  in  cases  of  this  kind,  as  well  as  in  perforative 
appendicitis,  intestinal  obstruction,  and  other  acute  abdominal  emergen- 
cies. The  phrase  seems  to  be  a  favorite  "blind"  behind  which  our 
ignorance  or  error  may  be  concealed.  I  have  never  yet  known  a  single 
case  in  which  the  diagnosis  was  justified  by  any  sufficient  chemical 
examination  either  of  the  food  supposed  to  be  responsible  for  the  trouble 
or  of  the  contents  of  the  gastro-intestinal  tract. 

The  patient  has  not  been  constipated,  exhausted,  or  neurotic;  he 
is  not  at  all  of  the  type  that  vomits  for  lack  of  any  other  occupation. 
We  may  be  forced  to  make  the  unsatisfactory  diagnosis  of  gastroneurosis, 
but  not  until  all  other  possibilities  are  exhausted. 

Tabes  dorsalis  with  gastric  crisis  was  at  first  seriously  considered, 
but  our  seriousness  was  disturbed  by  the  liveliness  of  the  knee-jerks. 
This  symptom  being  out  of  agreement  with  our  diagnpsis,  there  appeared 
to  be  nothing  but  the  sluggish  light  reaction  of  the  pupils  on  which  to 
base  the  diagnosis  of  tabes.  There  were  no  lightning  pains,  anomalies 
of  sensation,  or  sphincteric  disturbances.  Several  confirmatory  points 
had,  however,  been  o^•erlooked,  as  was  shown  by  the  outcome. 

Outcome. — It  was  subsequently  discovered  that  the  Achilles  jerk 
was  absent.  The  Wassermann  reaction  was  positive,  and  the  spinal 
fluid  showed  an  excess  of  lymphocytes. 

I'he  vomiting  persisted,  though  less  frequently,  until  the  fifth  of 
Sejitember.  After  that  it  ceased  and  convalescence  was  rapid.  Re- 
peated examinations  of  the  urine  were  negative.  No  treatment  that  was 
given  seemed  to  help  him. 

Diagnosis. — Tabes  with  gastric  crisis. 

Case  329 

An  Irish  laborer  of  forty-three,  of  good  family  liistory,  entered 
the  hos])ital  November  15,  1907.  He  has  had  no  disease  of  im- 
portance, though  he  has  been  in  sc\eral  dynamite  ex])losions  and 
sustained  various  wounds  and  burns.  \\'ithin  the  last  eight  years 
he  has  taken  no  alcohol,  and  before  that  nc\er  drank  to  excess.  He 
denies  venereal  disease. 

Since  the  last  explosion  in  which  he  was  in\"()l\ed  ten  months  ai^o 
he  has  vomited  once  or  twice  almost  every  day,  generally  in  the  niornini^ 
before  breakfast.  The  \omitus  consists  of  greenish  mucu>;  it  .-some- 
times contains  food  eaten  many  hours  l)efore.  He  has  seen  no  l(h>od. 
His  bowels  are  rather  loose,  mo\ing  three  to  se\en  times  a  day.  He 
has  no  pain,  a  fair  ap])etite,  and  he  has  kej)t  at  work  until  Mwenteen 


632  DIFFERENTIAL   DIAGNOSIS 

days  ago,  when  the  vomiting  became  almost  incessant  and  he  had  to 
give  up. 

On  examination  the  temperature,  pulse,  respiration,  blood,  and  urine 
are  normal. 

The  patient  is  obese,  shows  many  powder-marks  about  his  right 
eye  and  some  scars  in  the  cornea  of  both  eyes,  which  he  says  are  due  to 
the  old  explosion. 

Examination  of  the  nervous  system  and  internal  viscera  is  through- 
out negative.  No  contents  could  be  obtained  by  the  stomach-tube 
from  the  fasting  stomach,  which  held  only  26  ounces  without  distress. 
After  a  test-meal  the  gastric  contents  showed  free  HCl,  0.128  per  cent. 

Discussion. — Is  it  wise  to  believe  the  patient's  story  on  the  subject 
of  alcoholic  indulgence?  Is  it  not  more  probable  that  the  patient's 
vomiting  is  due  to  the  cause  usually  discoverable  in  such  cases?  How- 
ever this  may  be,  it  should  be  noted  that  vomiting  continued  in  the 
hospital  after  the  alcohol  had  been  withdrawn.  Moreover,  his  family 
and  friends  confirmed  his  account  of  his  habits. 

I  have  never  known  concealed  morphinism  in  a  man  of  this  type. 
Nevertheless,  it  is  always  a  possibility  to  be  reckoned  with  in  case  of 
unexplained  vomiting,  especially  if  there  are  wide-spread  pains,  insomnia, 
and  great  restlessness  associated  with  it. 

A  point  of  special  importance  is  the  patient's  obesity,  which  proves 
pretty  conclusively  either  that  his  vomiting  has  occurred  on  an  empty 
stomach  independent  of  food,  or  that  he  has  not  ejected  the  whole  of 
many  meals.  Many  a  patient  fails  to  take  account  of  the  difference 
between  emptying  the  stomach  and  merely  spilling  over,  as  a  baby  does, 
the  excess  of  what  has  been  eaten.  This  explains  the  astonishing  dis- 
crepancy often  confronting  us  between  the  patient's  account — "I  have 
vomited  every  meal  I  have  taken  for  weeks" — and  the  excellent  strength 
and  nutrition  of  his  tissues,  and  spares  us  the  necessity  of  assuming  that 
he  is  lying  or  consciously  exaggerating. 

As  we  go  OA-er  the  case  afresh  after  a  fruitless  search  for  organic 
lesions,  we  note  that  his  vomiting  followed  immediately  upon  a  d\Tiamite 
explosion.  Further  inquiry  may  ])erha])s  show  that  deep  impressions 
made  at  that  time  may  be  connected  with  the  habit  and  practice  of 
vomiting — that,  in  other  words,  we  may  be  dealing  with  a  traumatic 
neurosis.  This  must  not  be  assumed  without  a  careful  study  of  the 
patient's  mental  attitude,  as  It  Is  apt  to  be  revealed  on  close  questioning 
about  the  accident  and  what  has  hayjpened  since.  It  would  seem  strange 
that  a  man  who  has  been  through  several  explosions  should  lose  his 
nerve  for  the  first  time  In  the  last  one.     Only  further  Inquiry  and  experi- 


VOMITING 


633 


ment  can  decide.  Such  an  inquiry,  though  in  rather  an  abbreviated 
form,  was  undertaken. 

Outcome. — After  some  preliminary  questioning,  the  house  officer 
gave  the  patient  a  long  explanation  of  the  theory  and  practice  of  trau- 
matic neuroses,  explaining  the  supposedly  nervous  origin,  structure,  and 
development  of  the  trouble.  The  patient  accepted  everything  that  was 
told  him  as  absolute  truth,  and  began  at  once  to  eat  and  to  smoke  without 
any  discomfort  or  vomiting.  After  four  days  of  entire  freedom  from 
symptoms  he  was  discharged  well. 

Diagnosis. — Traumatic  neurosis. 

Case  330 

A  married  woman  of  fifty-one  entered  the  hospital  July  15,  1908. 
Her  family  history  is  good,  and  she  has  always  been  well,  although 
she  has  been  subject  to  belching  and  nausea  for  many  years.  "The 
amount  of  gas  that  forms  in 
my  stomach  is  beyond  belief," 
she  says.  She  has  taken  three 
cups  of  coffee  and  four  of  tea 
daily.  She  passes  water  two  or 
three  times  at  night.  Catamenia 
ceased  fourteen  years  ago. 

During  the  past  winter  and 
spring  she  was  having,  as  usual, 
a  good  deal  of  troul^le  with  gas 
and  distention  of  the  stomach, 
esj)ccially  at  night.  Toward  the 
end  of  May  she  had  an  attack 
of  "bloating"  somewhat  severer 
than  the  ]:)revious  ones,  accom- 
jjanied  by  epigastric  pain  and  by 
vomiting  of  a  sour  fluid.  At 
this  time  she  was  put  on  a  milk  ^'^-  ^^'^.-Chart  ,.f  case  ^.so. 

diet  and  stiiyed  in  bed.  Seven  weeks  ago  she  was  put  on  rectal  fewiing, 
and  this  was  continued  in  the  Hale  Hospital  at  Haverhill  for  the  last 
four  weeks.  She  has  gradually  \omiled  more  and  frequently,  no  matter 
what  she  eats  or  drinks,  e\en  in  the  absence  of  all  food  by  mouth.  She 
has  always  ])een  allowed  to  take  water  l)y  mouth.  At  the  ])resent  time 
her  vomitus  is  green  and  letter.  About  three  weeks  ago  slie  noticed 
about  a  teas])oonful  of  l)right  blood  in  the  vomitus.  l'".\en  niorphin, 
which  has  !)een  gi\en  in  considerable  (|uantities  for  tlie  la>t  \\eek,  has 


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634  DIFFERENTIAL   DIAGNOSIS 

not  sufficed  to  control  vomiting.  She  continues  to  have  gnawing  pain 
in  the  epigastrium,  running  up  the  sternum  to  the  throat. 

On  examination,  the  temperature  is  101°  F.,  the  pulse  88,  respira- 
tion 24.  The  patient  is  obese ;  the  pupils  small,  but  reacting  normally. 
Her  lungs  and  other  internal  viscera  show  nothing  abnormal.  The 
blood  is  negative,  likewise  the  urine,  except  for  the  presence  of  a  small 
amount  of  acetone  and  diacetic  acid.  The  guaiac  test  in  the  stool  and 
vomitus  is  negative. 

Discussion. — In  a  patient  who  vomits  with  a  temperature  of  loi  °  F., 
infectious  disease  is  the  first  possibility  to  be  investigated.  I  have 
repeatedly  seen  a  case  which  turned  out  to  be  pneumonia,  but  in  which 
constant  nausea  and  vomiting  were  the  only  complaints  for  three  days, 
cough  and  signs  of  solidification  being  wholly  absent.  Less  frequently 
one  sees  the  same  prolonged  nausea  at  the  outset  of  typhoid  or  malaria, 
and  in  children  in  almost  any  infection.  Even  if  physical  examination 
is  at  first  wholly  negative,  we  should  suspend  judgment  as  long  as 
the  temperature  remains  elevated,  and  continue  to  watch  for  the 
development  of  some  distinctive  symptom  betraying  infection.  \'omit- 
ing  itself  does  not  produce  fever. 

Some  type  of  organic  gastric  disease  or  some  of  the  extragastric 
lesions  simulating  it  should  next  be  looked  for,  although  at  present 
there  seems  nothing  definite  enough  on  which  to  base  a  conjecture. 

Lea\-ing  these  possibilities  for  the  present  undecided,  I  wish  to  call 
attention  to  two  points  of  interest: 

(a)  That  she  has  had  morphin  enough  in  the  past  week  to  prevent 
her  \omiting  from  ceasing  if,  by  chance,  it  showed  any  tendency  to  do 
so. 

(b)  That  she  is  still  obese  and  has,  therefore,  in  all  probability 
retained  and  absorbed  more  food  than  her  account  would  otherwise  lead 
us  to  suppose. 

Since  morphin  may  check  pain  or  vomiting,  many  physicians  are 
slow  to  realize  that  when  continued  more  than  a  few  days  it  has  a 
tendency  to  produce  in  many  persons  both  pain  and  \-omiting. 

The  first  move,  therefore,  should  be  to  stop  the  morphin  and  study 
the  condition  of  the  ])atient  when  free  from  its  influence.  The  size  and 
functions  of  the  stomach,  the  temperament  and  habits  of  the  patient, 
must  be  learned.  Thus  the  diagnosis  may  be  more  definitely  outlined. 
But  as  a  working  hypothesis  I  think  we  have  already  evidence  enough 
to  justify  us  in  following  the  clue  gi\-en  by  her  account  of  her  own  flatu- 
lence. A  history  of  this  kind  usually  points  to  a  habit  neurosis  dependent 
upon  cribbing. 


VOMITING  635 

Outcome. — The  patient  was  found  to  be  swallowing  air  constantly. 
She  was  given  at  once  a  liberal  diet  of  liquids  and  soft  solids,  with  a 
bitter  tonic  before  meals,  fluid  extract  of  cascara  for  her  bowels, 
and  Hoflfmann's  anodyne,  a  dram  at  night,  if  needed,  for  gas  and 
distress. 

In  the  four  days  following  her  entrance  to  the  hospital  the  patient 
vomited  only  once. 

Examination  with  the  tube  showed  no  fasting  contents,  no  enlarge- 
ment of  the  stomach,  and  after  a  test-meal,  free  HCl,  0.12.  The  patient 
was  kept  for  some  time  in  the  hospital  on  account  of  the  slight  fever, 
which  continued  for  something  over  two  weeks,  but  in  every  other  way 
she  seemed  entirely  well,  and  regained  her  confidence  before  the  twenty- 
fifth  of  July,  when  she  was  allowed  to  go  home.  The  cause  of  fever 
was  not  found. 

Diagnosis. — Gastric  neurosis. 

Case  331 

A  single  woman  of  thirty,  formerly  a  buyer  for  a  dry-goods  house, 
entered  the  hospital  March  i,  1907.  Four  years  ago  she  weighed  125 
pounds  and  was  strong  and  vigorous.  She  then  began  to  have  frequent 
stomachaches  and  much  doctoring,  both  of  which  have  continued  and 
got  worse  each  year.  She  had  an  osteopath  for  two  years,  with  consider- 
able relief  to  her  stomach  symptoms. 

For  the  last  year  vomiting  has  been  her  chief  symptom.  It  has  no 
relation  to  the  quality,  quantity,  or  time  of  food.  Some  days  she  can 
eat  and  retain  her  meals.  Other  days  even  a  mouthful  makes  her 
vomit. 

Three  weeks  ago  she  was  operated  on  for  a  floating  kidney.  Since 
then  she  has  vomited  everything.  She  is  convinced  that  the  operation 
was  unnecessary  and  harmed  her  stomach.  She  is  hungry  and  slcc])s 
well,  liut  is  very  weak  and  weighs  only  67  pounds. 

On  examination  the  ])atient  is  much  emaciated  and  nervous,  but  not 
des])ondent.  The  glands  in  the  neck,  axilla-,  and  groins  are  slightly 
enlarged;  the  heart-sounds  weak  and  Milvular;  a  systolic  wliilT  i> 
closely  confined  to  the  apex  region;  no  enlargement;  the  ])ulni()nciry 
second  sound  is  slightly  louder  than  the  aortic  second  sound. 

n"hc  l)l()od-])ressure  is  05  mm.  Hg.  Oc-casional  rales  are  heard 
over  the  large  bronchi.     The  lungs  are  othenvisc  negati\e. 

The  aorta  and  the  iliac  arteries  are  easily  i)al])al)lc,  but  the  abdomen 
shows  nothing  abnomial.  Hemoglobin.  75  per  cent.,  wliite  cells,  5200. 
Temperature,  jmlse,  respiration,  and  urine,  nomial. 


6.:;6 


DIFFERENTIAL   DIAGNOSIS 


The  stomach-tube  showed  the  gastric  capacity  to  be  46  ounces. 
The  outlines  of  the  inflated  stomach  were  as  shown  in  the  accompanying 
diagram  (Fig.  171).  There  was  food  in  the  fasting  stomach.  HCl  was 
absent  both  in  the  fasting  contents  and  after  a  test-meal.  There  was 
no  reaction  to  guaiac  in  the  stools  or  gastric  contents. 

Discussion. — Though  there  is  nothing  in  the  physical  signs  to 
suggest  tuberculosis,  one  must  always  search  with  extra  care  for  evi- 
dences of  this  disease  when  a  patient  is  so  emaciated  and  presents  such 
marked  gastric  symptoms  at  the  age  of  thirty.  The  low  blood-pressure 
also  points  in  the  same  direction,  but  in  the  entire  absence  of  fever,  and 
without  more  definite  physical  signs  in  the  lungs, 
abdomen,  bones,  or  glands,  we  cannot  take  another 
step. 

Cancer  of  the  stomach  is  very  rare  at  this  age, 
yet  the  emaciation,  the  evidences  of  gastric  stasis, 
and  the  absence  of  hydrochloric  acid  compel  us 
to  give  it  consideration.  As  bearing  on  this  ques- 
tion it  is  of  importance  to  note  that  the  symptoms 
are  of  long  duration  and  gradual  onset — very  un- 
usually so  for  gastric  cancer.  The  good  appetite 
is  another  point  against  cancer,  likewise  the  absence 
of  blood  in  the  stomach-contents  and  in  the  stools. 
The  patient  is  so  thin  that  we  should  expect  to  feel 
a  tumor  if  any  were  present,  especially  as  the  disease 
has  lasted  so  long.  On  the  whole,  it  seems  well  to 
adopt  some  other  working  hypothesis. 

The  position  of  the  upper  gastric  border  of 
the  stomach  proves  that  we  are  dealing  with  gas- 
troptosis  as  well  as  gastrectasis,  and  makes  it 
quite  possible  that  the  enlargement  may  be  due  wholly  to  the  dropping. 
Whether  any  "  benign  "  form  of  stenosis  is  present  at  the  pylorus  can  be 
determined  only  by  palpation,  and  by  the  results  of  our  efforts  at  induc- 
ing the  stomach  to  empty  itself  more  thoroughly.  E\en  in  a  warm 
bath  and  with  the  most  j)erfect  relaxation  of  the  abdominal  walls,  no 
induration  could  be  felt  in  the  region  of  the  pylorus,  which  was  unusually 
accessible  to  the  hand,  owing  to  the  low  position  of  the  whole  organ 
("afterward  demonstrated  by  bismuth  and  .r-ray  picture). 

As  a  result  of  these  investigations  and  of  a  good  many  studies  of  the 
patient's  mental  state  it  seemed  clear  that  we  were  dealing  with  a  vicious 
circle.  The  ])atient's  fruitless  regrets  and  fulminations  about  the 
a]jparently  useless  operation  doubtless  helped  to  aggravate,  and  were 


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case  331. 


of 


Fig.    171. — Shows   percussion   outlines   (also  visible)   after  intlation   of   the  stomach  in 

Case  331. 


VOMITING  637 

in  turn  aggravated  by,  the  stasis  in  her  prolapsed  stomach.  Such  a 
vicious  circle  usually  has  some  point  of  least  resistance  either  on  the 
physical  or  the  mental  side.  We  break  it  by  striking  at  that  point, 
ascertained  by  experiment  or  as  a  result  of  previous  knowledge  of 
similar  cases.  In  the  present  case  it  seemed  well  to  attack  first  the 
gastric  stasis,  and,  by  conquering  that,  to  improve  the  general  nutrition, 
thereby  mitigating  the  mental  fermentation.  Other  cases  may  be  best 
attacked  from  the  mental  side. 

It  may  be  well  to  say  a  word  in  passing  of  the  dangers  of  under- 
taking any  operation  in  such  a  patient  except  in  genuine  emergencies. 
I  may  here  refer  to  the  interesting  and  suggestive  article  of  Dr.  Stuart 
McGuire  on  "Latent  and  Active  Neurasthenia  in  its  Relation  to  Sur- 
gery," Jour.  Amer.  Med.  Assoc,  March  26,  1910.  As  the  result  of  a 
slight  ortho})edic  or  cosmetic  operation  done  at  an  unfavorable  time 
in  a  neurasthenic  patient,  I  have  seen  acute  and  intractable  exacerba- 
tion of  all  the  patient's  previous  troubles  reinforced  by  a  host  of  new 
ones  which  tortured  the  patient  and  his  friends  for  a  year  thereafter. 
The  present  case  was  a  comparatively  mild  one  of  this  type,  but  I  have 
no  doubt  that  the  operation  made  her  far  worse  than  she  was  before, 
whether  the  kidney  remained  in  place  or  not. 

Outcome. — Under  daily  gastric  lavage,  liquid  and  soft  solid  diet 
for  the  first  two  days,  and  then  six  meals  with  dry  diet,  15  drops  of 
dilute  hydrochloric  acid  after  each  meal,  and  the  same  amount  of  tincture 
of  nux  vomica  before  meals,  the  patient  steadily  improved. 

The  food  residue  in  the  fasting  stomach  had  diminished  by  March 
19th  from  10  ounces  to  3  ounces.  The  patient  was  much  less  nervous, 
up  and  about  the  ward  daily.  On  the  twenty-third  she  weighed  79 
pounds  and  was  very  markedly  improved. 

Diagnosis. — Neurosis ;  gastroptosis. 

Case  332 

An  Irish  teamster  of  forty-six,  of  good  family  history,  entered  the 
hospital  February  21,  1908.  He  has  had  attacks  of  stomach  trouble 
like  the  present  one  on  and  off  for  ten  years;  nevertheless  he  has  kept 
at  work  ])ractically  all  the  time,  has  smoked  35  cents'  wortli  of  tobacco 
a  week,  and  axeraged  one  whisky  a  day.     He  denies  \enereal  disease. 

All  thnnigh  the  sumnier  and  autumn  his  stomach  wa>  in  bad  rendition, 
but  for  the  past  four  weeks  he  has  l)een  ha\ing  an  increasing  amount  oi" 
distress.  He  vomits  almost  daily,  often  four  f)r  fwc  time-  a  day,  and 
usually  in  large  amounts — two  or  three  ])ints  at  a  time.  Hi-  \-omilu- 
consists  of  food,  at  times  mi.xed  with  bro\vni>li  material.      Sometinii-  hr 


638 


DIFFERENTIAL   DIAGNOSIS 


has  seen  in  the  vomitus  food  eaten  forty-eight  hours  before.     There 
has  been  no  blood  recognized  as  such. 

He  has  also  epigastric  pain,  which  radiates  to  the  back  and  abdomen, 
severe,  but  always  relieved  by  vomiting.  Neither  pain  nor  vomiting 
bears  any  relation  to  meals,  so  far  as  he  knows.  His  appetite  is  excel- 
lent. He  eats  everything,  as  he  finds  that  he  vomits  as  much  on  a  milk 
diet  as  when  eating  solid  food.  He  insists  especially  that  he  is  all  right  if 
he  "  keeps  quiet,"  but  that  he  finds  it  hard  to  get  along  if  he  tries  to 
work.     Nevertheless,  he  has  worked  up  to  February  20th.     His  average 

^ weight  is  135  pounds.     Now  he  weighs  105,  though 

|^~Rf^^       he  does  not  think  that  he  has  lost  much  weight  of 
late. 

He  has  no  symptoms  except  those  above  mentioned. 
On  examination  the  patient  is  emaciated,  with  a 
dry,  somewhat  pale  skin;  the  cervical,  axillary,  and 
inguinal  glands  are  slightly  enlarged.  The  pupils  are 
normal  in  all  respects.  The  tongue  is  clean.  The 
arteries  are  palpable  and  tortuous.  The  brachials 
show  a  lateral  excursion. 

Physical  examination  is  otherwise  negative,  except 
for  slight  rigidity  of  the  right  rectus  abdominalis. 

White  cells,  15,400;  hemoglobin,  85  per  cent.; 
urine  negative;  temperature  as  seen  in  the  accom- 
panying chart. 

Examination  by  means  of  the  stomach-tube  showed 
that  the  stomach  held  60  ounces,  though  its  lower 
border  reached  only  to  the  level  of  the  na\'el  after  infla- 
tion, and  no  fasting  contents  were  obtained.  After  an 
Ewald  test-meal  the  contents  showed  free  HCl,  0.266  per  cent.;  total 
acidity,  0.348;  no  reaction  to  guaiac.  On  examination  in  a  warm  bath 
a  hard,  irregular  mass  the  size  of  a  plum  was  felt  in  the  right  upper 
quadrant  of  the  abdomen.  It  was  ^'ery  movable,  but  not  tender.  It 
could  l)c  grasped  in  the  fingers  and  mo\-ed  freely  from  a  point  beloA\- 
the  umbilicus  until  it  disappeared  behind  the  ribs.  It  was  not  obliterated 
by  inflation  of  the  stomach. 

Discussion. — We  are  dealing  here  with  a  case  of  long-standing 
stomach  trouble  which  leads,  in  the  patient's  forty-skth  year,  to  that  type 
of  persistent  vomiting  which  jjoints  to  gastric  stasis  and  dilatation.  It 
is  to  be  noted  that  vomiting  relie\es  pain  and  is  associated  with  a  good 
aj)petite,  a  clean  tongue,  and  a  high  gastric  acidity.     The  presence  cf  a 


Fig.      172. — Chart 
of  case  332. 


VOMITING  639 

very  movable  intra-abdominal  tumor  is  the  chief  remaining  point  of 
importance. 

.  Tumors  of  extreme  mobility,  as  to  whose  nature  any  doubt  is  enter- 
tained, almost  always  turn  out  to  be  connected  with  the  pylorus.  Float- 
ing kidney  is  usually  recognized  with  ease  if  its  mobility  is  extreme,  and 
there  are  no  other  tumors  of  this  type.  Those  connected  with  the  gall- 
bladder may  have  considerable  mobility,  but  their  other  characteristics 
usually  ser\e  to  distinguish  them. 

Tumors  at  the  pylorus  result  either  from  cancer  or  ulcer.  Against 
cancer  in  this  case  is  the  long  duration  of  symptoms,  the  retention  of 
appetite,  the  high  acidity,  and  especially  the  marked  relation  to  exer- 
tion; but  as  we  know  that  cancer  may  become  ingrafted  upon  ulcer, 
it  does  not  seem  possible  to  be  any  surer  of  our  diagnosis  without  la])a- 
rotomy.  On  the  whole,  though,  the  evidence  points  very  strongly  toward 
ulcer. 

Outcome. — On  the  twenty-eighth  the  abdomen  was  opened.  An 
area  of  induration,  with  glandular  enlargement  in  the  neighborhood, 
was  found  near  the  ])ylorus. 

Pylorcctomy  and  gastro-cnterostomy  was  done,  about  10  cm.  of  the 
lower  end  of  the  stomach  being  removed.  In  this  operation  there  were 
two  ulcers,  one  about  4  cm.  above  the  pylorus,  1.5  cm.  in  diameter, 
with  shar])ly  ])unched-out  edges  and  deep  excavations.  Its  base  was 
firm  and  gristly,  but  consisted  only  of  chronic  inllammatory  tissue. 
Another  ulcer  about  2  cm.  in  diameter,  with  a  similar  gristly  wall,  is  just 
above  the  pyloric  ring. 

The  ])atientleft  the  hospital  on  the  twenty-eighth  of  March,  seemingly 
(|uite  well. 

On  the  fifth  of  .\])ril,  1909,  the  patient  rc])orted  that  he  was  in  good 
liealth  and  working  regularly.  He  has  no  gastric  distress,  but  has  to 
eat  fne  times  a  day  in  small  amounts.  He  has  gained  markedly  in 
weight  and  strength. 

Diagnosis. — Gastric  ulcer;  ju'loric  stenosis. 

Case  333 

A  bar])er,  thirty-seven  years  old,  whose  father  died  of  Bright's 
disease,  was  first  seen  June  19,  1907,  com])laining  of  vomiting  >]k'11s 
wliich  ];egan  when  he  was  sixteen  years  old  and  liave  continued  about 
twice  a  year  e\er  since,  though  less  fre(|uent  in  the  last  ten  years.  He 
feels  a  "luni])  like  lead"  in  the  epigastrium  all  the  time  at  jiroent. 
and  cannot  remember  wlien  he  did  not  feel  it.  All  food  distresses 
him  about  ecjually.     His  a])])etile  is  good,  and  he  eats  slowly  and  at 


640 


DIFFERENTIAL   DIAGNOSIS 


regular  intervals.     The  bowels  are  always  constipated  unless  he  takes 
laxatives. 

Ten  days  ago  he  began  to  vomit  without  known  cause,  and  has 
since  then  rejected  everything  except  malted  milk.  The  vomitus  is 
chiefly  phlegm  in  small  amounts.  During  these  ten  days  he  has  per- 
spired during  the  earlier  part  of  the  night,  and  felt  very  cold  the  rest 
of  the  night.  His  sleep  has  been  dull  and  heavy.  He  thinks  he  has 
lost  weight.     He  has  been  able  to  do  no  work  for  this  same  period. 

The  course  of  the  temperature  is  seen  in  the 
accompanying  chart. 

The  patient  is  well  nourished,  slightly  pale, 
shows  some  concretions  of  blood  in  the  nose. 
Heart  and  lungs  are  negative,  likewise  the  ab- 
domen and  the  urine.  The  blood  shows  4000 
white  cells  and  60  per  cent,  of  hemoglobin. 

Discussion. — Our  first  impression  of  this  case 
would  be  that  it  is  one  of  chronic  indigestion  of 
unknown  cause  (gastric  neurosis,  chronic  ulcer, 
chronic  appendicitis),  with  an  acute  exacerbation 
perhaps  due  to  constipation  or  some  temporary 
nervous  disturbance.  But  for  the  negative  ex- 
amination of  the  urine  and  the  absence  of  head- 
ache, one  might  suspect  chronic  Bright's  disease 
or  cerebral  tumor,  both  of  which  I  have  known  to 
show  themselves  in  this  way  in  a  patient  with  a 
similar  history,  reaching  back  indefinitely  into  boy- 
hood. 

One  feature,  however,  arrests  attention:  In  the  present  vomiting 
spell,  which  seems  to  be  a  good  deal  worse  than  the  rest,  he  has  had 
night-sweats.  Although  the  daily  chart  (the  temperature  being  taken 
morning  and  evening)  shows  no  iever,  it  does  not  cover  the  period  during 
which  he  \\'as  complaining  of  night-sweats,  and  as  it  was  only  taken 
in  the  day-time,  there  may  well  have  been  a  febrile  rise  at  night  since 
his  entrance  to  the  hos|)ital,  as  well  as  before.  This  indication  sliould 
lead  us  to  search  for  evidences  of  tuberculosis  or  other  infectious  disease, 
more  especially  as  there  is  a  considerable  degree  of  anemia  manifested 
])y  the  lowered  hemoglol)in  percentage. 

Such  a  lowering  of  the  liemoglobin  should  always  lead  us  to  the  study 
of  a  stained  specimen.  To  one  well  trained  in  routine  blood  work 
the  stained  specimen  would  h-dve  made  clear  the  diagnosis  in  this  case, 
yet  as  a  matter  of  fact  the  blood  has  already  ])een  examined  and  nothing 


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case  333. 


VOMITING  641 

found  to  suggest  what  was  wrong  with  the  patient.  A  good  example 
of  the  importance  of  competent  blood  examination  is  thus  furnished  in 
this  case  by  the  outcome. 

Outcome. — A  large  number  of  tertian  parasites — especially  the 
young,  unpigmented  ring  forms — were  found  in  the  stained  blood-smear, 
together  with  some  large  atypical  lymphocytes  exhibiting  phagocytosis 
of  red  cells.  Had  the  blood  been  examined  unstained,  as  is  often  done 
in  cases  of  suspected  malaria,  these  parasites  would  probably  not  have 
been  recognized. 

The  patient  was  given  10  grains  of  quinin  and  the  dose  was  repeated 
an  hour  later.  After  this  he  received  5  grains  every  four  hours  until  his 
ears  began  to  ring,  then  enough  to  keep  them  ringing  for  three  days.  In 
two  days  his  blood  was  free  from  parasites  and  his  vomiting  had  ceased. 

I  may  add  a  word  here  concerning  other  atyjjical  forms  of  malaria — 
i.  e.,  those  which  do  not  begin  with  the  familiar  tertian  chill.  Among 
the  malarial  fevers  of  temperate  climates,  almost  all  of  which  are  due 
to  the  tertian  organism,  I  have  noted  the  following  unusual  clinical 
types: 

(a)  A  case  beginning  with  violent  maniacal  delirium  without  other 
distinguishable  symptoms. 

(b)  Cases  beginning  with  intense  headache  and  stupor,  closely 
simulating  the  onset  of  meningitis.    * 

(rj  A  case  beginning  with  violent  pain  in  both  axillary  regions  and 
along  the  lower  costal  margin. 

(d)  A  group  of  cases  already  referred  to  (see  p.  140)  which  simulated 
appendicitis,  owing  to  the  se\"ere  pain  in  the  right  iliac  region  or  in  the 
epigastriun^. 

(e)  Cases  in  which  headache,  slee])iness,  or  muscular  weakness  re- 
curred every  day  or  every  other  day  at  the  same  hour. 

In  estivo-autumnal  malaria  persistent  diarrhea  may  be  the  only 
striking  symptom.  A  very  large  num1)cr  of  cases  occurring  in  children 
are  mostly  or  altogether  latent.^ 

In  all  these  atypical  cases  diagnosis  is  comparatively  simple,  pro^ 
vided  we  are  led  to  make  a  careful  examination  of  the  stained  blood-film; 
without  this,  diagnosis  may  be  impossible. 

Diagnosis. — Tertian  malaria. 

iScp  Crai^,  "  Latent  Infections  in  Malaria,"  lH.'ini^  Part  III,  Chapter  1\',  of  his  Ixiok 
on  Malarial  levers. 


642 


DIFFERENTIAL  DIAGNOSIS 


Case  334 


A  sewing  woman  of  fifty-nine,  always  previously  in  good  health, 
entered  the  hospital  June  7,  1906.  She  felt  perfectly  well  in  the  morn- 
ing, four  days  ago,  and  went  to  call  upon  a  friend.  While  there  she 
was  suddenly  seized  with  nausea  and  vomited  several  times.  She  was 
taken  home,  went  to  bed,  but  felt  mean  and  nauseated  all  the  next  day. 
She  has  not  been  able  to  work,  and  has  been  in  bed  practically  all  the 
time  since,  vomiting  a  little  each  day.  She  feels  "  all  gone  "  and  weak,  is 
very  drowsy  and  sleepy,  and  has  had  rather  a  severe  headache  since  the 
onset.  The  bowels  are  moved  with  medicine.  She  gets  up  once  or  twice 
at  night  to  urinate;  she  has  a  very  slight  dry  cough. 

The  patient  is  obese;  the  pupils  are  ecjual  and  react  normally.  The 
tongue  is  clean,  the  heart  and  arteries  normal.  There  are  a  few  crack- 
ling rales  in  both  backs,  especially  at  the  bases. 

For  temperature,  see   the  accompanying 
chart. 

The  abdomen  and  reflexes  are  normal. 
The  urine  a\'erages  40  ounces  in  twenty- 
four  hours,  102 1  in  specific  gravity;  no  albu- 
min; many  hyaline  and  fine  granular  casts. 

Discussion. — The  very  acute  onset  and 
the  association  with  headache  and  drowsiness 
suggest  some  implication  of  the  brain.  Men- 
ingitis or  brain  tumor  sometimes  show  them- 
selves for  the  first  time  in  this  way,  but  when 
we  follow  out  the  tests  indicated  by  these 
hints,  there  seems  to  be  nothing  to  confirm 
them.  Nephritis  also  might  indirectly  pro- 
duce cerebral  S}Tnptoms  like  these,  and  the 
habit  of  nocturnal  urination,  together  with 
the  abundance  of  tube-casts,  gives  some  war- 
rant to  this  idea.  The  other  characteris- 
tics of  the  urine,  however,  do  not  bear  it 
out.  and  as  there  is  fever  in  the  case,  the  presence  of  casts  can  be  thus 
accounted  for.  The  evidence  would  ])e  more  complete  upon  this  point 
if  we  had  an  accurate  measurement  of  the  systolic  blood-pressure. 

Other  diseases  which  often  begin  in  this  way  are  pneumonia  and 
the  gastric  crises  of  tiibes  dorsal  is.  Occasionally  a  i)aroxysm  of  vomit- 
ing is  the  only  manifestation  of  an  attack  of  nephrolithiasis.  None  of 
these  clues,  however,  turned  out  fruitful  when  followed  u])  in  this  case. 


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334- 


;f   case 


VOMITING 


643 


The  correct  diagnosis  was  actually  suggested  for  the  first  time  by 
the  temperature  chart,  which  shows,  as  will  be  at  once  obvious,  a  tertian 
fever.  Such  fever  is  by  no  means  pathognomonic  of  malaria;  I  have 
known  it  to  occur  in  tuberculosis  and  in  various  types  of  sepsis.  Never- 
theless, it  could  hardly  fail  to  remind  us  that  malaria  may  begin 
with  nausea  and  vomiting  and  thus  lead  us  to  a  careful  blood  ex- 
amination. 

Outcome. — The  day  after  entrance  the  patient  had  a  chill,  and  par- 
asites were  looked  for,  but  in  vain.  It  was  not  until  the  third  day 
that  the  malarial  parasites  were  discovered. 

On  the  fourteenth  the  patient  had  a  rise  of  temperature  and  vomited, 
though  she  had  been  taking  quinin,  5  grain  every  six  hours,  since  the 
eleventh.     After  that  day,  however,  she  had  no  more  fever  or  vomiting. 

Diagnosis. — Malaria  (tertian). 


Case  335 

A  school-boy  of  sixteen  was  first  seen  August  24,  1907.     His  family 
history  and  past  history  are  excellent.     Last  winter  he  entered  high 
school  and  worked  very  hard.     This  spring  he 
seemed    tired    out,    and    had   headaches,    sup- 
posedly due  to  eye-strain. 

Two  weeks  ago  he  began  to  vomit.  For 
four  days  he  could  retain  no  food,  and  for  a 
week  more  vomited  each  morning.  The  bowels, 
meantime,  were  constipated,  but  the  appetite 
was  good  throughout.  During  these  two  weeks 
he  has  frequently  been  chilly  or  feverish,  his 
hands  and  feet  being  cold.  He  has  complained 
of  headache  and  pains  in  his  back  and  legs, 
with  slight  cough.  Throughout  he  has  been 
very  weak.  For  the  ])ast  three  days  there  has 
Ijeen  delirium. 

^\'hen  seen,  the  ])aticnt  was  in  a  muttering 
delirium,  with  twitching  of  the  face.  He  was 
poorly  nouri>hed.  The  course  of  the  tempera- 
ture is  seen  in  the  accom])anying  chart.  The 
chest  showed  nothing  ;i1)nonnal.  The  abdomen 
was    Hat,  rather   tense,  tymi)anitic    throughout, 

and  apparently  not  tender.  Rellexes  were  normal.  There  were  no 
rose-sj)ots.  There  was  incontinence  of  urine  and  feces,  but  the  urine 
showed  nothing  abnomial. 


644  DIFFERENTIAL   DIAGNOSIS 

White  cells,  'jooo;  hemoglobin,  80  per  cent.;  Widal  reaction,  entirely 
negative. 

The  case  was  believed  to  be  one  of  typhoid  fever  with  meningeal 
irritation. 

Discussion. — When  a  boy  of  sixteen  is  suddenly  attacked  by  fever 
and  vomiting  in  the  middle  of  summer,  no  exanthem  or  other  obvious 
cause  being  visible,  malaria  is  one  of  the  first  diseases  to  be  considered. 
It  was  easily  excluded,  however,  hi  this  boy's  case  by  blood  examuiation. 

Brain  tumor,  especially  solitary  tubercle  of  the  cerebellum,  some- 
times begins  in  this  way,  and  without  an  examination  of  the  fundus  one 
can  hardly  exclude  it  with  certainty.  It  would  be  unusual,  however, 
to  find  no  hint  tending  to  localize  the  trouble  in  any  particular  part  of 
the  brain  (vertigo,  staggering  gait,  strabismus). 

Typhoid  fever  was  the  diagnosis  actually  made  in  the  early  days  of 
this  illness.  The  negative  Widal  reaction  seemed  to  be  of  no  great 
significance,  since  this  reaction  is  so  often  absent  in  the  earlier  stages 
of  typhoid.  The  early  onset  of  delirium  and  the  relaxation  of  the 
sphincters  were  accounted  for  by  meningeal  irritation  (meningismus) , 
In  all  such  cases,  however,  experience  has  taught  me  that  it  is  wise  to  do 
lumbar  puncture.  Several  times  I  have  known  typhoid  mistaken  for 
tuber'^ulous  meningitis  and  a  hopeless  prognosis  given  in  consequence. 
When  the  child  got  well  and  the  diagnosis  of  typhoid  became  obvious, 
the  family  were  not  pleased  with  the  prognosis  previously  given  by  the 
medical  attendant.  In  the  present  case  the  opposite  mistake  was  made, 
and  a  falsely  hopeful  prognosis  was  given. 

Outcome. — On  the  twenty-seventh  his  neck  was  found  to  be  stiff. 
Lumbar  puncture  showed  10  c.c.  of  clear,  colorless  fluid,  the  sediment 
of  which  showed  95  per  cent,  lymphocytes.  A  culture  of  blood-serum 
remained  sterile. 

The  Widal  reaction  was  tried  daily,  but  continued  negative.  The 
ear-drums  were  examined  without  result. 

On  the  twenty-ninth  the  neck  became  more  relaxed  and  the  patient 
quieter. 

A  second  lumbar  puncture,  September  ist,  gave  essentially  the  same 
results  as  before.  Some  of  this  fluid  was  injected  into  a  guinea-pig. 
The  patient  became  unconscious  on  the  second  of  December  and  died 
on  the  fourth. 

Throughout  the  first  week  of  his  stay  in  the  hospital  he  was  treated 
for  typhoid;  later  he  was  fed  by  stomach-tube,  milk,  beef-juice,  and 
eggs  being  introduced  in  this  way. 

October  7th  the  guinea-pig  which  had  received  the  spinal  fluid  inter- 


VOMITING  645 

peritoneally  was  killed,  and  showed  tuberculosis  of  the  spleen  and 
lymphatic  gland. 

Diagnosis. — Tuberculous  meningitis,  [presumably  with  general  mil- 
iary tuberculosis].    . 

Case  336 

A  married  woman  of  thirty-four,  of  good  family  history  and  past 
history,  entered  the  hospital  March  9,  1908.  She  had  a  miscarriage 
five  weeks  ago,  in  the  fourth  month  of  pregnancy,  following  a  hard 
day's  work  of  washing.  There  was  considerable  hemorrhage  both 
before  and  after  the  miscarriage.  She  was  curetted  at  the  time,  but  has 
been  very  weak  and  confined  to  bed  ever  since.  During  the  first  three 
or  four  days  after  the  miscarriage  she  had  two  chills,  but  there  has  been 
no  fever,  so  far  as  she  knows. 

For  the  past  three  weeks  she  has  vomited  persistently  and  has  been 
able  to  retain  no  solid  food.  It  is  chiefly  for  this  symptom  that  she  seeks 
advice. 

On  examination,  the  pulse,  temperature,  and  respiration  are  normal. 
The  })atient  is  well  nourished,  slightly  pale,  pupils  equal  and  reacting 
normally,  the  tongue  thickly  coated  white,  the  left  tonsil  slightly  enlarged, 
about  half  of  the  teeth  missing.  The  heart's  impulse  is  not  seen  or  felt. 
The  sounds  are  best  heard,  and  the  left  border  of  dulncss  found,  in  the 
fourth  sj)ace,  five  inches  to  the  left  of  the  midsternal  line,  one  inch  out- 
side the  midclavicular  line.  The  sounds  arc  regular  and  of  good  quality, 
the  pulse  of  low  tension. 

The  lungs  are  normal,  the  abdomen  considerably  tender  above  the 
symphysis  and  at  McBurney's  point.  The  patient  has  many  varicose 
veins  in  the  right  lower  leg,  and  two  white  scars  said  to  be  due  to  ])revious 
ulcers. 

lilood  and  urine  not  abnormal. 

Discussion. — The  salient  facts  a])pcar  to  ])c  as  follows:  Obstinate 
^■om^ting  following  miscarriage  and  associated  with  slight  enlargement 
of  the  heart  and  a])dominal  tenderness  es])ecially  marked  in  the  ap])cndix 
region. 

This  group  of  s}Tiiptoms  does  not  easily  cohere  into  any  of  the  tradi- 
tional groui)S  which  we  call  diseases.  The  cardiac  signs  arc  slight — 
o1)\iously  too  slight  to  account  for  the  vomiting  as  a  result  of  ]Kissive 
congestion.  There  is  no  kidney  change  to  account  for  tlie  cardiac 
enlargement,  or  to  suggest  uremia  as  a  reason  for  tlie  \oniiting.  There 
are  no  brain  s)Tn])toms,  and  though  a  fimdus  examination  would  be 
a  satisfactory  com])letion  of  our  record,  it  is  not  urgcntl}  called  for  by 


646  DIFFERENTIAL  DIAGNOSIS 

the  other  symptoms  of  the  case.  Malaria  and  other  infectious  diseases 
are  ruled  out  by  the  entire  absence  of  fever. 

The  abdomen  deserves,  of  course,  our  special  attention.  Is  it 
possible  that  the  general  tenderness  may  be  the  result  of  some  type  of 
peritonitis,  a  low-grade  septic  infection,  or  tuberculosis?  The  evidence 
is,  on  the  whole,  insufficient  to  justify  any  such  belief.  There  are  no 
muscular  spasm,  no  free  fluid  or  masses — nothing  more,  in  fact,  than 
one  finds  after  a  miscarriage  in  a  great  many  uncomplicated  cases.  In 
the  absence  of  fever,  leukocytosis,  elevated  pulse,  or  more  distmctive 
local  evidences  appendicitis  seems  unlikely. 

A  more  thorough  investigation  of  the  pelvis  is  indicated.  Although 
we  know  very  little  about  the  connections  between  the  vomiting  center 
and  the  genital  tract,  connections  whereby  so-called  reflex  vomiting  of 
pelvic  disease  is  supposed  to  arise,  it  is  a  very  familiar  fact  that  a  ^•ariety 
of  low-grade  inflammatory  changes  in  the  puerperal  uterus,  complicated 
no  doubt  to  a  greater  or  lesser  extent  by  absorption  from  incompletely 
organized  thrombi,  may  lead  to  well-marked  constitutional  disturbances, 
of  which  vomiting  is  one.  Whether  this  comes  about  through  the 
nervous  system,  by  the  aid  of  the  vomiting  center,  and  favored  by  psychic 
disturbances,  or  whether  it  is  in  some  way  a  more  direct  result  of  infec- 
tion, I  know  no  way  of  determining  at  the  present  time.  But,  however 
this  may  be,  it  seems  clear  that,  when  we  have  finished  our  task  of 
excluding  the  other  possibilities  mentioned  above,  the  best  remaining 
hypothesis  on  which  we  may  base  treatment  is  that  which  assumes  that 
the  vomiting  is  in  some  way  connected  with  the  residual  effects  of  the 
miscarriage. 

Outcome. — The  patient  was  put  to  bed  and  given  30 minims  of  fluid- 
extract  of  ergot  at  once,  and  15  minims  three  times  a  day  after  meals. 
There  was  some  reddish  vaginal  discharge  without  odor.  The  uterus 
was  moderately  enlarged,  freely  movable,  and  somewhat  tender.  By  the 
twenty-second  the  uterus  was  much  smaller  and  less  tender.  The 
vomiting  ceased  after  the  third  day.  The  treatment  consisted  of  laxa- 
tives and  a  daily  suds  enema. 

Diagnosis. — -Incomplete  miscarriage. 

Case  337 

A  stationary  engineer  of  fifty-seven  was  first  seen  January'  21,  1907. 
Two  of  his  brothers  and  one  sister  died  of  consumption.  His  wife  is 
said  to  have  died  of  tuberculosis  of  the  bowels.  He  has  himself  been 
well  except  for  so-called  rheumatic  ])ains  referred  to  the  muscles  of  the 
back  and  extremities.     These  he  has  had  for  many  vears. 


VOMITING  647 

Eight  years  ago  he  was  poisoned  by  steaming  oxalic  acid,  and  was 
sick  a  w'eek,  with  vomiting,  diarrhea,  and  abdominal  pain.  Since  that 
time  he  has  had  occasional  attacks  of  a  similar  nature  about  twice  a  year, 
lasting  three  or  four  days. 

His  usual  weight  is  184.  He  has  passed  urine  frequently  at  night 
for  a  number  of  years. 

Seven  months  ago  he  began  to  have  frequent  attacks  of  vomiting, 
coming  on  quite  suddenly  during  a  meal,  or  soon  after  it,  and  without 
any  pain,  nausea,  or  distress.  He  has  Nomited  every  day  for  some 
months — often  two  or  three  times  a  day.  There  has  never  been  any 
large  amount  of  vomitus,  nor  any  indication  of  food  eaten  the  previous 
day.  The  appetite  has  been  poor,  his  bowels  very  loose.  He  has  lost 
color,  weight,  and  strength  very  rapidly.  Six  months  ago  he  was  obliged 
to  take  to  bed,  where  he  remained  two  months,  and  got  somewhat 
better.  Diarrhea  and  vomiting  improved  decidedly,  and  he  gained  in 
weight,  but  at  the  end  of  another  month  he  relapsed  and  had  to  take  to 
bed  again  for  most  of  the  succeeding  months.  His  complaints  are  now 
the  same  as  they  were  seven  months  ago.  He  has  never  vomited  blood. 
The  character  of  the  food  has  ap])arently  no  efTect  on  the  vomiting. 
Seven  months  ago  he  weighed  184  pounds;  four  months  ago,  142;  three 
months  ago,  153;  now  he  weighs  125  pounds. 

On  examination  the  patient  is  pale.  The  heart's  a])ex  is  in  the  fifth 
space,  inside  the  nipple-line;  there  are  no  murmurs,  no  accentuations 
of  any  sound.  The  pulses  are  of  high  tension,  the  artery  wall  apparently 
somewhat  thickened.  The  abdomen  shows  distinct  resistance  in  the 
epigastric  region  and  beneath  the  right  costal  border.  Otherwise  it  is 
negative. 

The  blood  showed:  Red  cells,  2,796,000;  white  cells,  9400.  of 
which  84  per  cent,  are  polynuclcar,  the  rest  h-mphocytes.  There  is 
no  achromia  and  no  other  change  except  slight  deformities  in  the  red 
cells. 

The  urine  is  30  ounces  in  twenty-four  hours,  and  contains  a  large 
trace  of  albumin,  many  ])us~cells,  no  casts.     Gravity,  1012-1016. 

The  stools  are  negative  to  guaiac  and  show  no  al)normal  fcod  residues. 

Discussion. — The  family  history  of  tul)erculosis  is  so  threatening: 
in  this  case  that  one  would  naturally  begin  diagnostic  in\estigation> 
with  a  search  for  ex'idencc  of  ]>hthisis  or  some  other  fonn  of  tul)ercuh)sis. 
This  was  done,  l)ut  without  result. 

Since  his  occu|)ation  does  not  inx'ohe  any  constant  exno^ure  to  tlic 
oxalic  acid  by  which  he  was  poisoned  eiglit  years  ago,  tlurc  appears  to 
be  no  reason  to  connect  his  svm])toms  with  this  poison. 


648  DIFFERENTIAL   DIAGNOSIS 

The  loss  of  weight,  the  anemia,  the  age  of  the  patient,  and  the  method 
of  onset  suggest  ulcer  or  cancer  of  the  stomach.  The  symptoms  have 
lasted  so  long,  however,  that  stasis  would  probably  have  manifested 
itself  before  this  time.  It  is  remarkable  also  that  the  food  he  takes 
has  apparently  no  relation  to  the  vomiting. 

Gastritis  and  enteritis,  without  some  obvious  cause,  such  as  alcohol, 
uncompensated  cardiac  lesions,  tropical  dysentery,  or  chronic  nephritis, 
are  distinctly  rare  diseases  in  a  man  of  this  age.  There  is  nothing  in  the 
study  of  the  stools  or  of  the  vomitus  to  justify  any  such  belief;  neither 
of  these  diseases  is  apt  to  be  accompanied  by  severe  anemia  unless  a 
great  deal  of  blood  has  been  discharged. 

It  is  often  profitable,  in  the  discussion  of  such  a  case,  to  begin  with 
the  well-established  fact  of  secondary  anemia  and  study  the  rest  of  the 
disease  from  the  point  of  view  of  the  possible  cause  of  such  an  anemia. 
I  have  previously  referred  to  a  case  (see  p.  539)  in  which  severe  anemia 
was  produced  by  long-standing  hemorrhoids  with  bleeding,  altogether 
unknown  to  the  patient.  Such  a  cause  was  sought  for  in  the  present  case, 
but  not  found. 

Obscure  anemia  in  a  patient  of  this  age  very  often  turns  out  to  be  of 
cancerous  origin.  It  did  not  seem  to  me,  at  the  time  that  the  case  came 
under  my  observation,  that  the  possibility  of  gastric  cancer  had  been 
sufficiently  investigated,  and,  accordingly,  I  adAised  further  study  of 
the  gastric  contents  and  functions.  Nothing  of  importance  was  elicited, 
however.  The  capacity  of  the  stomach  was  within  normal  limits, 
there  was  no  stasis,  and  although  the  amount  of  free  hydrochloric  acid 
was  very  small,  this  fact  could  not  be  interpreted  as  of  any  importance 
in  relation  to  the  possibility  of  cancer,  since  it  could  be  explained  in  so 
many  other  ways.     The  guaiac  test  was  negathe  in  the  gastric  contents. 

Chronic  nephritis  was  next  considered,  since  it  is  a  familiar  fact 
that  long-standing  irritation  of  the  stomach  and  intestines,  with  or 
without  a  catarrhal  inllammatlon,  often  complicates,  and  is  the  main 
cause  of,  distress  in  this  disease.  Little  could  be  found  to  support  this 
idea.  There  was  no  demonstrable  enlargement  of  the  heart.  Un- 
fortunately, the  blood-i)ressure  was  not  measured,  so  that  we  could  not 
be  certain  that  our  digital  Impressions  really  corresponded  to  hyper- 
tension, as  they  were  supposed  to  do.  The  urine  was  not  Incompatible 
with  nephritis,  but  not  characteristic  of  It— a  very  familiar  and 
baffling  state  of  things. 

Although  the  patient's  habits  were  supposedly  excellent,  the  resist- 
ance beneath  the  right  costal  border,  the  unexplained  anemia  and  per- 
sistent vomiting,  made  us  speculate  concerning  the  possibility  of  a  cir- 


VOMITING  649 

rhosis,  but  we  found  no  means  of  advancing  beyond  the  region  of  specu- 
lation upon  this  point.  In  the  end  the  diagnosis  was  very  uncertain. 
Fewer  objections  were  raised  against  the  diagnosis  of  chronic  nephritis 
with  uremic  vomiting  than  against  any  other,  but  none  of  us  felt  satisfied. 

Outcome. — The  patient  grew  progressively  weaker,  and  died  on 
the  twenty-eighth. 

Autopsy  showed  chronic  interstitial  nephritis,  a  very  firm,  rubbery 
dark  liver,  enteritis  and  gastritis,  with  chronic  colitis,  and  terminal 
streptococcus  septicemia. 

Diagnosis. — (See  above.) 

Case  338 

A  barber  of  thirty-five  with  an  excellent  family  history  and  past  history, 
entered  the  hospital  January  11,  1908.  He  has  been  having  business 
reverses  for  the  past  four  weeks,  during  which  he  has  slept  poorly  and 
become  very  nervous. 

On  the  night  of  December  27  he  fell  down  eight  or  nine  stairs  and 
bruised  his  right  hip,  which  has  improved  somewhat  under  poulticing, 
but  is  still  lame  and  stiff  and  has  confined  him  to  bed. 

The  night  after  this  fall  he  began  to  vomit,  and  has  continued  to  do 
so  three  or  four  times  a  day,  and  once  at  night  ever  since.  The  vomitus 
at  first  consisted  of  food  in  considerable  amounts;  later,  of  a  frothy 
liquid  and  mucus.  Once  or  twice  there  has  been  a  small  streak  of 
blood.  His  bowels  meantime  have  mo^•ed  from  two  to  six  times  a  day, 
with  considerable  griping  pain  and  gas.  Throughout  there  has  been 
a  dull,  steady  pain  in  the  epigastrium,  with  a  sense  of  dragging  when 
he  sUmds  or  sits  u]),  but  no  especial  pain.  His  food  has  been  milk, 
eggs,  oysters,  and  cool  drinks. 

On  examination,  the  temperature,  pulse,  respiration,  blood,  urine, 
and  internal  viscera  are  all  negative,  except  that  the  abdomen  is  held 
rather  rigidly  and  that  there  is  some  tlattening  of  the  right  lower  chest 
in  front.  aj)])arcntly  connected  with  a  funnel-breast  deformity. 

Examination  of  the  stools  showed  no  blood  to  any  test  and  no  abnor- 
mal food-remains. 

Discussion. — Gastro-cntcritis  is  the  usual  diagnosis  in  such  a 
case,  but  while  it  is  impossible  positively  to  exclude  such  an  ufi"ection. 
I  think  it  is  unwarrantable  to  assume  it^  jjresence  when  the  stools  and 
the  gastric  contents  furnish  no  better  evidence  of  intlamnviticm.  The 
presence  of  mucus  in  the  \omitus  and  the  occasional  small  streak  of 
blood  are  in  no  way  distincti\e.  Almost  any  case  characterized  by 
persistent  vomiting  shows  such  jjroclucts  now  and  then. 


650  DIFFERENTIAL   DIAGNOSIS 

The  abdominal  rigidity  leads  us  to  think,  at  least  for  a  moment,  of 
.some  type  of  peritonitis,  but  there  is  not  a  single  other  fact  to  support 
this  idea.  Surely  there  would  be  some  change  in  the  temperature, 
pulse  or  blood,  were  peritonitis  present.  Moreover,  any  patient  who 
has  recently  vomited  a  good  deal  is  apt  to  hold  his  abdomen  rather 
rigidly  when  the  palpating  hand  explores  it. 

It  is  worth  noticing  that  the  vomiting  came  on  immediately  after 
the  patient  had  been  confined  to  bed  by  the  injury  to  his  hip.  The 
isolation,  the  inactivity  and  the  deprivation  of  all  occupation  or  interest 
produced  by  putting  a  patient  to  bed  will  give  him  a  splendid  opportunity 
to  dwell  upon  the  worried  and  depressing  events  which  had  previously 
made  hun  nervous  and  sleepless.  One  is  justified  in  laying  stress  upon 
these  factors  in  a  case  of  this  kind  when  careful  physical  examination 
furnishes  no  explanation  of  the  symptoms.  Treatment  should  be 
planned  in  accordance  with  the  possibility  that  the  symptoms  may  be 
psychic  in  origin,  though  greatly  aggravated,  no  doubt,  by  physical 
exhaustion  and  starvation. 

Outcome. — The  patient  was  given  a  liquid  and  soft-solid  diet, 
gentian  and  nux  before  meals,  and  trional,  15  grains,  at  night  for  two 
nights.  In  the  three  days  following  the  beginning  of  this  treatment  he 
had  no  vomiting  whatever,  and  declared  that  he  felt  perfectly  well. 
Doubtless  the  reassurance  given  him  as  the  result  of  a  negative  physical 
examination  contributed  to  his  reco\'ery. 

Diagnosis. — Nervous  exhaustion. 

Case  339 

A  motorman  of  forty-four  entered  the  hospital  May  8,  1908.  His 
family  history  and  past  history  are  rather  uneventful,  but  he  admits 
that  he  has  lost  much  weight.  Four  years  ago  he  weighed  210  pounds; 
now  he  weighs  159.  He  has  not  worked  since  October,  1907,  because 
of  stomach  trouble.  For  the  first  two  weeks  of  his  illness  he  vomited 
everything  that  he  had  eaten,  the  sour  vomitus  consisting  of  undigested 
food,  but  never  containing  blood. 

Soon  after  recovering  from  this  he  had  "  the  grip,"  and  was  in  bed 
for  several  weeks.  Since  then  he  has  had  wandering  pains,  "  like  rheuma- 
tism," in  the  shoulders,  hips,  and  abdomen.  He  has  not  been  confined 
to  bed,  and  he  was  able  to  walk  to  the  hospital,  though  he  complains 
of  considerable  weakness.  He  has  had  a  cough  all  winter  until  last 
week — since  then,  none.  His  appetite  is  poor,  likewise  his  sleep. 
The  bowels  are  moved  daily.  (For  tem])erature,  see  the  accompanying 
chart.) 


VOMITING 


6:;i 


The  patient  is  emaciated,  the  heart's  apex  in  the  fourth  interspace, 
inside  the  nipple-line,  the  sounds  of  good  quality.  The  pulmonic 
second  sound  is  slightly  accentuated. 

At  the  apex  of  the  right  lung  there  are  a  few  fine  crackles  after  cough 
and  a  slight  prolongation  of  expiration.  In  the  left  back  there  is  a  tri- 
angular area  of  dulness,  with  its  apex  at  the  spinal  column,  ih  inches 
above  the  lower  angle  of  the  scapula ;  thence  it  slopes  out  into  the  mid- 
scapula.  Over  this  area  tactile  and  vocal  fremitus  are  absent,  breathing 
distant  and  bronchovesicular.  Just  above  this  area  the  voice  has  a 
nasal  quality.     The  abdomen,  blood,  and  urine  are  normal. 

The  sputum  was  twice  examined  for  tubercle 
bacilli,  with  negative  results. 

Discussion. — The  onset  of  well-marked  gas- 
tric symptoms  in  a  man  of  fort\-four  whose 
stomach  has  never  troubled  him  previously, 
should  always  compel  us  to  consider  gastric 
cancer,  but  more  especially  so  when  the  physical 
examination  of  the  rest  of  the  body  reveals 
nothing  which  might  be  a  cause  for  the  gastric 
disturbances.  This  can  hardly  be  said  to  be  the 
case  here,  so  that  our  attention  is  properly  concen- 
trated first  upon  the  extragastric  causes  which 
might  lead  to  his  present  gastric  symptoms. 

Nothing  is  said  regarding  the  reflexes  in  this 
record.  Without  a  knowledge  of  their  condition 
it  would  be  impossible  for  us  to  exclude  tabes 
dorsalis  with  gastric  crises.  Further  investiga- 
tion, however,  showed  that  all  the  reflexes  were 
normal. 

The  most  important  abnormalities  discoverable  on  physical  examina- 
tion are  in  the  lungs,  and  though  these  signs  are  not  extensive,  they 
lead  us  to  ask  whether  so  much  emaciation  and  stomach  trouble  could 
be  produced  by  any  well-known  disease  affecting  the  lungs.  This  ques- 
tion must  be  answered  in  the  aflirmativc.  Nothing  is  more  familiar 
than  the  ])roduction  of  such  a  clinical  ])icture  as  a  result  of  pulmonary 
tuberculosis.  But  have  we  evidence  of  enough  pulmonary  disease  to 
explain  such  severe  constitutional  manifestations?  This  point  ]  have 
discussed  in  previous  cases.  Ex])eriencc  has  made  us  very  familiar 
with  the  discrepancy  often  existing  between  the  extent  of  the  discovera- 
ble physical  signs  and  the  severitv  of  the  constitutional  manifestations, 


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Fig.    176. — Chart   of 
case  339. 


652  DIFFERENTIAL  DIAGNOSIS 

such  as  fever,  sweats,  chills,  emaciation,  and  gastro-intestinal  disturb- 
ances. 

It  is  quite  possible  that  some  degree  of  secondary  gastritis  may  arise 
as  a  result  of  lowered  powers  of  resistance  produced  by  tuberculosis, 
but  postmortem  evidence  does  not  compel  us  to  make  any  such  assump- 
tion. 

No  weight  should  be  laid  upon  the  absence  of  tubercle  bacilli  in  the 
sputum  examined  in  this  case.  Such  tests  are  of  importance  only  when 
many  times  repeated. 

Outcome. — X-ray  showed  a  deep  shadow  over  the  lower  part  of 
the  left  chest.  The  upper  margin  of  this  shadow  had  an  irregular  out- 
line, and  did  not  suggest  the  existence  of  any  considerable  pleural  efiu- 
sion.  There  was  also  a  slighter  shadow  corresponding  to  the  left  apex. 
The  patient  was  discharged  to  a  sanatorium  for  tuberculosis 

Diagnosis. — Phthisis. 

Case  340 

A  woman  of  fifty-six,  a  post-office  clerk,  of  good  family  history  and 
past  history,  entered  the  hospital  January  9,  1908.  She  passed  the 
menopause  six  years  ago  without  trouble.  Throughout  the  past  summer 
she  has  been  bothered  by  sour  stomach  and  flatulence. 

Five  days  ago  she  ate  canned  salmon  for  supper,  and  that  night, 
after  going  to  bed,  she  felt  very  chilly,  headachy,  vomited  and  sweated 
profusely.  The  next  two  days  she  also  vomited  a  good  deal,  and  during 
the  last  two  days  has  been  extremely  nauseated.  Throughout  these 
five  days  she  has  had  aching  all  over  her  body,  has  slept  very  little,  and 
has  felt  feverish.  The  matter  vomited  has  been  either  food  or  a  greenish- 
colored  material.  The  bowels  have  moved  twice  in  five  days.  She  has 
eaten  practically  nothing. 

For  the  last  three  days  she  has  had  a  constant,  irritating,  dry  cough. 

Physical  examination  was  negative,  save  that  in  the  left  upper  chest 
and  in  the  right  axilla,  at  the  extreme  base,  were  a  few  transient,  fine 
moist  r^Ies.  Temperature,  102°  F.;  pulse,  100;  respiration,  20;  white 
cells,  19,500;  hemoglobin,  90  per  cent.;  Widal  reaction,  negative; 
urine,  negative. 

Discussion.— The  acute  onset  of  symptoms  in  this  case  naturally 
and  properly  turns  our  attention  for  the  time  being  away  from  the  long- 
standing causes  of  vomiting,  such  as  have  been  discussed  in  previous 
cases.  It  is  true  that  some  of  these  chronic  diseases — such  as  brain 
tumor,  nephritis,  gastric  cancer,  or  neurosis — may  suddenly  be  "lighted 
up''  or  roused  to  unusual  activity  after  having  remained  latent  for  a  long 


VOMITING  653 

dme,  but  few  if  any  of  them  would  then  be  associated  with  such  marked 
fever,  leukocytosis,  and  general  constitutional  signs  pointing  to  infection. 

It  is  reasonable,  therefore,  to  consider  whether  any  well-known 
infection  is  prone  to  begin  in  this  way.  Infections  of  the  gas tro- intestinal 
tract  are  uncommon  and  still  more  uncommonly  recognizable.  Typhoid 
sometimes  starts  out  with  prolonged  gastro-intestinal  disturbances, 
but  the  high  leukocyte  count  is  sufficient  to  exclude  any  uncomplicated 
type  of  this  disease.  The  same  is  true  of  acute  or  incipient  tuberculosis, 
except  in  the  meningeal  form.  The  unknown  infections,  usually  termed 
"grip"  or  "ptomain-poisoning,"  are  much  less  likely  to  produce  such 
leukocytosis  and  such  continued  vomiting  than  is  one  possibility — next 
to  be  mentioned. 

Of  all  the  severe  infections  which  are  apt  to  attack  elderly  people 
in  or  near  the  month  of  January,  pneumonia  is  the  one  most  often 
beginning  with  gastro-intestinal  sym])toms  alone.  The  leukocytosis, 
the  cough,  and  the  trifling  chest  signs  are  all  quite  consistent  with  this 
idea.  Yet  no  one  could  make  a  positive  diagnosis  of  pneumonia  from 
the  facts  here  ])resented.  A  blood-culture  might  enable  him  to  do  so, 
since  the  pneumococcus  is  not  infrequently  to  be  found  in  the  circulating 
blood  before  any  evidence  of  solidification  has  become  manifest  in  the 
lungs.  Without  culture  one  can  only  suspect  pneumonia,  the  ])ractical 
s^nificance  of  which  act  consists  in  what  it  leads  us  to  say  to  the  family, 
together  with  the  focusing  of  our  attention  on  the  results  otf  rejx^ated 
exiiminations  of  the  lungs.  In  many  cases  with  exactly  such  signs  as 
are  here  recorded,  the  stethoscope  reveals  nothing  characteristic,  but 
with  the  free  ear  against  the  chest-wall  we  may  be  able  to  detect  a  dis- 
tant but  quite  distinctive  tubular  breathing. 

Outcome.— Twenty-four  hours  after  the  above  record  was  taken 
there  a])])carcd  in  the  left  u]>pcr  lobe,  below  the  clavicle  in  front,  dulness, 
diminished  breathing,  diminished  \oice  sounds,  and  many  fine  and 
medium  moist  rales.  Although  the  Ijreathing  was  of  diminished  intensity, 
the  expiration  and  the  whis])ercd  voice  were  high-j)itchcd  and  relatively 
intense.     The  patient  had  no  dysjmea  and  no  pain. 

On  the  elc\enth  the  white  cells  were  28,000;  on  the  thirteenth,  24,(^^0: 
on  the  fifteenth,  7600. 

There  were  no  sputa  at  any  time  and  practically  no  cough.  Hy 
the  sixteenth  the  abnormal  sounds  were  less;  by  the  twenty-second 
they  were  gone. 

The  patient  com])lained  \ery  much  of  al)domina]  (H<tres^  and  numb- 
ness. She  vomited  occasionally  on  the  following  day-,  and  it  was  sug- 
gested that  she  ouglit  to  have  a  s])ecial  nur>e  and  Ix,-  U'd  l>y  the  boud. 


654 


DIFFERENTIAL  DIAGNOSIS 


February  ist  she  announced  that  she  would  like  to  sit  up,  and  her  appetite 
began  to  return;  this  was  not  until  her  temperature,  pulse,  and  respira- 
tion had  been  normal  for  seventeen  days. 

On  the  third  of  February  she  complained  of  being  paralyzed  all 
over.  On  questioning,  "paralysis"  turned  out  to  mean  numbness,  and 
there  was  not  the  slightest  sign  of  impaired  motion  nor  of  impaired  sensa- 
tion anywhere. 

Diagnosis. — Pneumonia. 

Case  341 

An  unmarried  Canadian  woman  of  twenty-seven,  of  good  family 
history  and  past  history,  was  first  seen  November  21,  1906.  She  has 
had  occasional  indigestion  for  the  past  two  or  three  years,  and  of  late 
has  been  run  down  and  anemic.  Catamenia  have  been  absent  for  the 
past  two  and  one-half  months.  For  eight  weeks  she  has  had  nausea 
and  vomiting  almost  every  day,  sometimes  several  times  a  day.  Vomit- 
ing may  follow  food,  but  at  times  she 
retches  when  the  stomach  is  empty.  Loss 
of  weight  and  strength  has  been  such  that 
ten  days  ago  she  was  obliged  to  go  to  bed, 
in  spite  of  which  vomiting  has  continued. 
Five  days  ago  she  began  to  have  dull 
pain  in  the  lower  left  chest,  increased  by 
deep  breathing  or  cough.  At  the  same 
time  she  began  to  be  short  of  breath.  For 
two  weeks  she  has  had  cough,  occasion- 
ally raising  thick,  yellow,  l^lood-streaked 
sputum.  (See  accompanying  chart  for 
the  temperature.) 

On    examination  the  heart's  apex  is 

not  seen   or  felt.       The   right  border  of 

cardiac  dulness  appears  to  extend  3^  inches 

to  the  right  of  midsternum.     The  sounds 

are  clear,  but  are  best  heard  to  the  right 

of  the   sternum.      The  condition  of   the 

lungs  is  shown  in  tlie  accompanying  diagram  (Figs.  178  and  179).    The 

abdomen  shows  nothing  abnormal.    The  reflexes  are  also  normal.    The 

white  cells  are  5500;  the  urine  negative. 

On  the  twenty-second  74  ounces  of  yellow,  slightly  turbid  fluid 
were  withdrawn  from  the  chest.     Specific  gravity  was  1018;  albumin, 


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Fig.  178. — Signs  recorded  in  a  case  characterized  ap])arently  l)y  vomiting  (eight  weeks' 
duration);  only  within  live  da_\s  have  pain  and  dysi)nea  ai)peared. 


Fig.   I  7Q. — Signs  as  rccordi-d  in  Case  311.      Note  absence  of  any  record  of  para\erleliral 
clulnesd  ((Irocco's  signj  o\\  the  riLjht.       In    i(;o(>  \\  e  had   nol  been   lauulit  tu  l«n)k  for  it. 


VOMITING  655 

4  per  cent.  In  the  sediment  small  lymphocytes  made  up  98.5  per  cent. 
No  tubercle  bacilli  could  be  demonstrated  from  the  digested  clots. 

After  the  tapping  the  patient  ceased  vomiting  and  felt  finely.  By 
December  ist  there  was  no  vomiting  at  all;  then  it  returned  in  occa- 
sional attacks,  and  by  the  twelfth  it  was  causing  a  great  deal  of  trouble. 
Free  fluid  had  reaccumulated  in  the  chest  to  a  slight  extent  only,  but 
the  patient  seemed  to  be  losing  ground. 

Discussion. — The  pleurisy  which  was  so  easily  demonstrable  in 
this  patient's  chest  seemed  at  first  a  sufl&cient  reason  for  her  vomiting. 
We  were,  therefore,  surprised  that  the  vomiting  continued  after  the 
effusion  had  been  tapped.  Neither  the  temperature  chart  nor  any 
of  the  other  signs  in  the  case  seemed  to  indicate  that  the  tuberculosis, 
presumably  in  the  background  of  this  pleural  effusion,  was  the  cause 
of  the  vomiting. 

There  appeared  to  be  no  reason  to  suspect  organic  disease  of  the 
stomach,  brain,  heart,  or  kidney.  There  was  no  constipation  or  toxemia 
apparent.  We  might  have  been  tempted  to  settle  down  on  the  unsatis- 
factory diagnosis  of  "gastric  neurosis."  One  fact,  however,  still  re- 
mained unexplained — namely,  the  amenorrhea.  This  was  not  to  be 
accounted  for  by  anemia  or  by  any  obvious  psychic  cause.  Clearly, 
it  was  our  duty  to  investigate  the  possibility  of  pregnancy. 

Outcome. — Tuberculous  salpingitis  was  suspected.  Vaginal  ex- 
amination showed  a  mass  in  the  pelvis,  distinguishable  from  the  uterus, 
softer  and  more  fluctuant  on  the  right  than  on  the  left.  A  great 
number  of  remedies  for  vomiting  were  tried,  among  them  sodium 
bicarbonate,  i  dram  in  half  a  glass  of  hot  water,  sipped,  Hofi"mann's 
anodyne,  i  dram  in  hot  water,  ginger-ale  with  sodium  bicarbonate  in 
sips,  mustard  leaf  to  the  epigastrium,  bismuth  and  beta-naphthol, 
cerium  oxalate,  2  grains  every  two  hours,  and  various  diets.  Finally, 
on  the  fourteenth  of  December  she  was  put  on  nutrient  enemata  and 
all  food  by  mouth  omitted.  As  the  {)atient  continued  to  \omit  and 
retch  at  times,  though  the  nutrient  enemata  were  well  retained  and  did 
not  cause  discomfort,  it  seemed  best  again  to  explore  the  ])elvis,  with 
a  view  to  freeing  the  adhesions  and  perhaps  stoj)ping  the  vomiting  in 
this  way.  Accordingly,  on  the  twenty-first  the  abdomen  was  opened  and 
showed  nothing  but  a  large,  ])resumably  ])regnant  uterus,  with  nomial 
tubes  and  ovaries.  Within  live  days  after  this  ex])l oratory  operation 
vomiting  ceased  altogether. 

Diagnosis. — Vomiting  of  pregnancy;  pleural  elTusion. 


6^6  DIFFERENTIAL   DIAGNOSIS 


Case  342 


A  Russian  tailor  of  thirty-seven  entered  the  hospital  April  28,  1908. 
He  has  found  himself  unable  to  work  for  several  months,  because  when- 
ever he  tries  to  move  about  at  all  he  vomits.  This  vomiting  is  accom- 
panied by  shortness  of  breath  and  palpitation.  He  has  also  a  slight 
cough,  anorexia,  constipation,  and  insomnia.  He  has  noticed  no 
edema. 

On  examination,  the  right  pupil  is  slightly  larger  than  the  left.  The 
heart's  apex  is  in  the  fifth  space,  one  inch  outside  the  left  nipple.  At 
the  apex  there  is  a  murmur  which  lasts  through  the  whole  of  diastole 
with  a  crescendo  toward  its  end.  The  first  apex  sound  is  very  sharp, 
and  preceded  by  a  palpable  thrill.  The  pulmonic  second  sound  is  not 
accentuated.  There  are  crackles  and  squeaks  scattered  throughout 
both  lungs,  especially  at  the  base  behind,  where  there  are  slight  dulness 
and  diminished  fremitus. 

In  the  abdomen,  there  is  a  little  dulness  laterally  when  the  patient 
is  lying  down,  this  dulness  shifting  with  change  of  position. 

Physical  examination,  including  the  blood  and  urine,  is  otherwise 
negative. 

Discussion. — Attention  should  be  arrested  by  an  unusual  com- 
bination of  symptoms  present  in  this  case — viz.,  vomiting,  excited, 
apparently,  by  exertion.  This  is  a  very  significant  grouping  of  facts, 
and  may  be  interpreted  to  mean  either  that  vomiting  is  dependent 
upon  some  circulatory  disturbance  which  exertion  increases,  or  upon  the 
shifting  of  the  position  of  some  viscus  when  he  assumes  the  upright 
position. 

vSince  the  vomiting  is  associated  with  other  symptoms  suggesting 
disturbance  of  the  circulation  and  the  physical  examination  reveals  a 
cause  for  this  disturbance,  we  must  ask  whether  mitral  stenosis,  which 
is  a])parently  the  lesion  present,  is  capable  of  producing  such  persistent 
vomiting,  even  when  compensation  is  not  xery  seriously  disturbed. 
Experience  shows  that  we  may  answer  this  question  in  the  affirmative, 
although,  as  a  rule,  troublesome  gastro-intestinal  symptoms  do  not 
occur  until  rather  later  in  the  course  of  an  uncompensated  cardiac 
lesion. 

Since  physical  examination  gives  us  no  hint  of  any  other  cause  for 
the  vomiting,  it  is  proper  to  treat  the  patient  with  reference  purely  to 
his  circulatory  disturbance,  and  to  anticipate  that  he  will  stop  vomiting 
when  his  compensation  is  improved. 

Outcome. — The  patient  was  kept  in  bed,  given  an  ounce  of  magne- 


VOMITING  657 

sium  sulphate  each  morning,  and  a  bitter  tonic  before  meals.  Occa- 
sionally he  needed  10  grains  of  trional  to  induce  sleep,  but  no  cardiac 
stimulation  seemed  called  for.  After  a  week's  rest  he  was  in  good 
condition  and  had  no  symptoms  as  long  as  he  did  not  exert  himself 
violently. 

Diagnosis. — Mitral  stenosis. 

Case  343 

A  Swedish  tailor  of  fifty,  with  a  good  family  history  and  past  histor\', 
entered  the  hospital  June  12,  1907. 

About  February  i,  1907,  he  began  to  have  abdominal  pain  and 
vomiting.  At  first  his  pain  was  relieved  by  belching  sour  gas,  but  it 
gradually  became  more  severe,  especially  after  eating  meat  or  heavy 
food,  less  after  milk  or  crackers. 

For  the  past  two  months  the  pain  comes  three  or  four  hours  after 
eating,  and  is  very  severe  and  grinding,  passing  from  right  to  left  across 
the  epigastrium,  and  relieved  by  vomiting,  which  is  apt  to  occur  once 
or  twice  every  two  or  three  days,  usually  after  a  siege  of  pain.  He  has 
often  seen  in  the  vomitus  food  eaten  a  day  or  two  before.  Usually  the 
vomitus  contains  the  unchanged  food  and  bile-stained  mucus,  never 
more  than  a  ])int  at  a  time,  never  dark  or  bloody. 

He  has  constantly  lost  weight,  strength,  and  color.  In  February  he 
weighed  152  pounds,  now  he  weighs  131.  He  is  constipated;  sleeps 
well.  He  gets  up  two  or  three  times  at  night  to  pass  water.  His  appetite 
is  excellent.     He  worked  until  two  days  ago. 

Examination  showed  emaciation,  pallor,  negative  chest  and  abdomen. 

White  cells,  5000;  hemoglobin,  75  per  cent.;  urine,  normal.  The 
stomach  held  70  ounces  of  water;  after  a  test-meal,  free  HCl  was  absent 
on  two  occasions.  Total  acidity,  0.12  and  0.2.  Stools  altogether 
nomial.     The  fasting  stomach  contained  considerable  food  remnants. 

After  a  few  days  in  the  hos])ital  on  a  dry  diet  divided  into  six  meals 
daily,  HCl,  20  minims  after  meals,  and  2  drams  of  Carlsbad  stilts  each 
morning,  the  symptoms  disapiicarcd. 

There  was  at  no  time  any  \isible  peristalsis. 

Two  days  after  lea\-ing  the  hospital  the  pain  recurred  and  a  profu>e 
diarrhea  l)cgan. 

On  July  24th,  1Q07,  he  reentered  the  hos])ital.  complainiriL^  tliat 
he  had  had  since  his  last  entry  five  or  six  attacks  similar  to  that  just 
described,  ])eginning  with  severe  abdominal  pain  followed  by  vi^niitinix 
and  diarrhea.  Most  of  these  attacks  ha\c  followed  some  inrlixretion 
in  diet.     As  in  tiie  j^revious  illness,  he  lias  noticed  in  \\  hat  he  \omit> 


658  DIFFERENTIAL   DIAGNOSIS 

food  eaten  a  day  or  more  before.     The  appetite  is  good,  bowels  con 
stipated.     He  sleeps  well  except  during  the  attacks  of  pain. 

The  abdomen  now  shows  marked  rigidity  and  tenderness  in  the  right 
lower  quadrant,  but  no  masses  are  made  out.  The  hemoglobin  has  now 
fallen  to  50  per  cent. 

Discussion. — Gastric  cancer  is  strongly  suggested  by  this  history. 
Here  is  a  man  who  has  lived  on  peaceful  terms  with  his  stomach  for 
forty-nine  years  and  then,  without  any  discoverable  cause,  begins  to 
have  trouble  with  it.  The  regular  recurrence  of  pain  three  or  four 
hours  after  eating  is,  however,  less  characteristic  of  cancer  than  of 
ulcer  and  some  other  diseases.  Quite  obviously  we  have  stasis,  emacia- 
tion, and  anemia,  presumably  of  the  secondary  type.  These  facts, 
together  with  the  absence  of  hydrorhloric  acid,  still  further  support  the 
hypothesis  of  cancer,  especially  as  no  hemorrhage  or  other  cause  for  the 
anemia  is  manifest. 

Though  we  were  much  inclined  toward  the  diagnosis  of  gastric  cancer, 
the  disappearance  of  symptoms  after  a  few  days'  stay  in  the  hospital  made 
us  more  doubtful.  Marked  improvement  does,  however,  occur  in 
cases  of  undoubted  gastric  cancer,  and  I  have  often  known  a  false  con- 
clusion based  upon  such  improvement.  Doubtless  the  secondary 
irritation  of  the  gastric  mucous  membrane  resulting  from  the  stasis  is 
itself  the  cause  of  many  of  the  symptoms  in  gastric  cancer.  When  this 
stasis  is  relieved  by  diet  and  lavage,  the  symptoms  improve,  though  the 
cancer  does  not. 

By  the  time  of  his  second  entrance  to  the  hospital  we  had  begun  to 
notice  certain  anomalies  in  the  clinical  picture,  which  made  it  difficult 
to  identify  it  with  that  of  gastric  cancer.  First  of  all,  it  was  notable 
that  the  pain  passed  across  the  epigastrium  from  right  to  left — i.  e., 
against  the  current  of  the  gastric  contents.  This  is  unusual  in  pyloric 
obstruction.  Next,  we  were  forced  to  observe  that  the  pain  had  not 
the  steady,  grinding  character  usually  seen  in  the  more  painful  types 
of  gastric  cancer,  nor  was  it  confined  to  that  indefinite  distress  and 
sense  of  weight  which  characterizes  the  less  painful  types  of  the  disease. 
This  man's  pain  came  in  distinct  paroxysms  of  great  severity,  separated 
by  intervals  of  com])lete  freedom.  This  is  more  suggestive  of  intestinal 
than  of  gastric  cancer.  Hie  profuse  diarrhea  following  his  last  stay 
in  the  hos|)ital,  and  the  consti])ation  which  has  been  a  feature  of  his  case 
throughout,  fall  in  Aery  well  with  this  idea. 

If  we  are  dealing  with  chronic  intestinal  obstruction,  as  this  last 
interpretation  of  the  sym])toms  seems  to  indicate,  there  is  reason  to 
believe  that  cancer  is  its  cause,  both   because  the  great  majority  of 


VOMITING  659 

such  cases  occurring  in  men  of  this  age  turn  out  to  be  cancerous  and 
because  the  anemia  is  not  otherwise  explicable. 

Outcome. — Subsequently  a  hard  mass  with  indefinite  outline  was 
made  out  on  the  right  side  of  the  abdomen,  at  the  le\  el  of  the  navel. 

Rectal  examination  was  negative,  but  the  stools  now  exhibited  a 
marked  reaction  to  guaiac.  After  a  test-meal  the  stomach-contents 
showed  free  HCl,  0.018. 

Leukocytes,  4100,  among  which  59  per  cent,  were  jjolynuclear,  30 
per  cent,  lymphocytes,  11  per  cent,  eosinophiles. 

Operation  on  the  twenty-seventh  showed  cancer  of  the  ascending 
colon. 

Diagnosis. — Cancer  of  the  ascending  colon. 

Case  344 

A  married  woman  of  fifty  years  was  first  seen  in  September,  1903, 
for  major  hysteria.  After  this  she  passed  out  of  my  ken  and  I  did  not 
see  her  again  until  December  8,  1908.  During  this  time  she  had  gol 
into  the  habit  of  taking  brandy  at  the  rate  of  about  a  quart  a  week  at 
irregular  intervals;  also  a  s])ray  of  cocain,  which  she  used  two  or  three 
times  a  day  for  most  of  the  time.  Besides  this,  she  had  a  prescri})tion 
for  amylene  hydrate,  originally  given  her  by  Brown-Sequard,  and  con- 
tinued by  her  at  intervals  ever  since. 

She  has  been  more  or  less  hors  de  combat,  owing  to  the  influence  of 
hysteria  and  drugs,  for  a  considerable  ]X)rtion  of  the  time.  Two  and  a 
half  weeks  ago  she  got  overtired  with  shopping  and  the  theater.  Within 
a  day  or  two  she  began  to  have  persistent  vomiting,  headache,  and 
great  irritability,  which  at  times  amounted  almost  to  delirium,  and  was 
accomy)anied  by  suicidal  impulses,  This  continued  until  within  the 
present  week,  when  she  Ijecame  very  quiet  and  drowsy  most  of  the 
time,  but  continued  to  vomit.  As  far  as  can  be  estimated,  she  has 
consumed  about  a  quart  of  brandy  in  the  last  three  days. 

For  the  ])ast  four  days  it  has  been  noticed  that  the  amount  of  urine 
has  considera])ly  diminished.  Yesterday  afternoon  it  was  examined 
flnd  found  to  contain  0.5  per  cent,  of  albumin.  Il  was  smoky  in  color. 
and  in  the  sediment  were  a  great  manv  casts,  chiefly  flne  granular 
and  brown  granular,  with  a  smaller  number  of  the  hyaline  and  cellular 
types.  It  was  su1)se(|uently  learned  that  she  liad  had  albumin  in  the 
urine  four  years  ])reviou>ly,  but  its  other  characteristics  were  not  known. 

I'or  the  ])ast  twehe  hours  slie  had  been  semieons(•iou^-.  and  as  we 
went  upstairs  the  attending  phvsician  said  to  me  that  the  ca^e  ^einied 
to  him  \ery  grax'e;   he  doubted  somewhat  w  hetlur  she  u'uld  be  roused. 


66o  DIFFERENTIAL   DIAGNOSIS 

We  stepped  to  the  bedside.  "Mrs.  D.,"  said  he,  "here  is  Dr.  Cabot. 
Do  you  remember  seeing  him  some  years  ago?''  "Yes,"  said  she,  "and 
a  bigger  fool  I  never  knew."  All  of  which  seemed  to  argue  that  she 
was  not  so  badly  off  after  all;  yet  she  soon  slipped  off  again  into  a  semi- 
unconscious  condition,  in  which  the  pupils  reacted  very  sluggishly. 

On  physical  examination  there  was  decided  muscular  negativism. 
The  heart  and  lungs  showed  nothing  abnormal ;  the  blood-pressure  was 
not  high ;  the  abdomen  was  negative.  There  was  no  muscular  paralysis, 
but  the  knee-jerks  could  not  be  obtained,  and  there  was  an  extraordinary 
degree  of  fia1)biness  in  the  calf  muscles — almost  no  muscle  left.  Else- 
where nutrition  was  fair.  Blood  examination  showed  nothing  wrong 
in  that  direction. 

Discussion. — As  there  was  no  muscular  tremor  and  no  suggestion 
of  alacrity  in  the  psychic  responses,  there  seemed  no  good  reason  to 
anticipate  delirium  tremens. 

Uremia  was  seriously  considered,  and  could  not  be  excluded.  The 
points  against  it  were  the  low  blood-pressure  and  the  muscular  relaxa- 
tion, also  the  emphatic  statement  by  the  husband  that  she  had  often 
"  been  as  bad  as  this  before,"  but  had  always  come  out  of  it  all  right  when 
alcohol  and  drugs  were  taken  away. 

On  the  other  hand,  it  seemed  difficult  to  account  for  the  bad  condi- 
tion of  the  urine  as  a  result  simply  of  alcoholism  and  cocain.  On  the 
whole,  I  was  inclined  to  think  her  uremic  and  to  give  a  bad  prognosis. 

Outcome. — Alcohol  and  drugs  were  stopped,  and  she  was  kept  on 
a  diet  of  milk  and  water  for  twenty-four  hours,  after  which  she  rebelled 
and  nibbled  a  considerable  quantity  of  various  objects.  Within  a  week 
the  urine  had  cleared  up  and  the  jmtient  was  decidedly  active  and  bad 
tempered,  but  insisted  on  running  her  automobile,  which  she  dro\e 
herself.  So  far  as  could  be  ascertained,  the  attack  had  passed  off  with- 
out leaving  her  any  worse  than  before,  and  without  producing  any  per- 
manent damage  in  her  internal  viscera. 

The  case  taught  me  a  lesson  not  unfamiliar  to  those  who  deal  with 
acute  alcoliolism  and  drug-poisoning,  viz.,  that  there  is  almost  no  limit 
to  the  amount  of  albumin  and  casts  which  may  be  excreted  in  the  urine 
of  patients  during  an  acute  attack  of  narcotic  poisoning,  without  leaving 
any  evidence  of  ])ermanent  damage  to  the  kidneys  after  the  attack 
])asses  olf.  One  should  attem]jt  no  judgment  about  the  condition  of  the 
kidneys  until  we  ha\e  been  alMc  to  eliminate  the  present  effect  of  alcohol 
and  other  narcotics. 

Diagnosis. — Hysteria;   alcoholism;   drug  habits. 


VOMITING  66 1 


Case  345 


AnneK.,  a  laundress  of  forty-eight,  entered  the  hospital  March  14, 
1909.  She  has  always  been  well  and  has  an  excellent  family  history. 
She  passed  the  menopause  a  year  ago.  On  the  morning  of  Christmas, 
1908,  after  a  hard  day's  work  preceding,  she  vomited  "half  a  washbowl 
of  phlegm"  when  she  first  got  up.  She  noticed  no  food  or  blood  in  the 
vomitus.  She  breakfasted  and  worked  as  usual  that  day.  Through 
January  and  February,  1909,  she  considered  herself  perfectly  well,  though 
her  bowels  had  been  more  than  usually  constipated,  and  when  once  started 
by  catharsis  there  had  often  been  a  slight  diarrhea  for  several  days. 

Three  weeks  ago  she  took  a  dose  of  salts  one  morning  for  one  of  her 
usual  spells  of  consti])ation  and  immediately  began  to  vomit  bile-stained 
phlegm.  Her  vomiting  continued  all  day,  though  she  kept  at  work. 
She  s])ent  the  next  three  days  in  bed  and  continued  to  vomit  after  eating. 
She  then  went  to  a  friend's  house  for  a  rest.  There  the  vomiting  soon 
ceased,  and  in  five  days  she  was  able  to  resume  work. 

A  week  later,  March  8,  1909,  vomiting  recurred  for  the  third  time. 
Nevertheless  she  ke])t  at  work  until  March  12th,  the  day  pre\ious  to  her 
entering  the  hospital.  The  vomitus  has  always  been  small  in  amount 
and  apparently  free  from  blood  or  food  residue.  She  says  she  has  had 
no  j)ain  at  any  time  except  a  "griping"  after  taking  a  cathartic. 

Ap])etite  poor,  sleep  excellent,  weight  (a  year  ago)  150  pounds. 
Her  mistress  says  that  she  has  always  been  reticent  and  uncomplaining. 

On  examination  her  weight  was  found  to  be  151  ])ounds,  and  she 
seemed  distinctly  ol)csc,  though  it  was  also  noted  by  one  of  the  consult- 
ants that  "her  flesh  hung  on  her  body  with  wrinkles  and  folds."  suggest- 
ing that  she  had  previously  been  heavier. 

Physical  examination,  including  the  blood  and  urine,  was  wholly 
negati\"e,  sa\e  for  a  very  slight  degree  of  abdominal  distention.  After  the 
bowels  had  Ijeen  started  by  a  glycerin  enema  of  4  ounces  on  March  13th 
and  a  high  oil  enema  of  6  ounces  March  15th.  they  continued  to  move 
normally.  The  stools  were  not  remarkable  either  in  number  or  appear 
ance,  and  showed  a  negative  guaiac  reaction  March  i()th,  17th.  and 
20th.  After  the  i8th  she  was  al)le  to  take  milk  and  crackers  without  any 
xomiting  or  distress.  March  2()th  slie  was  taking  a  full  diet  w  ithout  an\- 
symittoms,  and  April   ist  she  was  discharged  well. 

Discussion.  The  diagnosis  of  i^astrir  neurosis  and  (Oiislifxil.'on  w  a- 
made  in  this  case.  The  ])asis  for  this  was  chielly  the  neiratiNc  iih\'r-i(al 
examination,  and  the  pr()mi)t  recovery  of  gastric  and  inle-tinal  tunction 
under  rest  and  diet,  with  enemata. 


662  DIFFERENTIAL   DIAGNOSIS 

We  were,  therefore,  (juite  astonished  and  somewhat  amused  when 
Dr.  E.  A.  Codman,  who  saw  her  March  i8th,  made  a  diagnosis  of  chronic 
intestinal  oljstruction,  probably  due  to  cancer.  Yet  the  outcome  showed 
that  Dr.  Codman  was  in  all  probability  right.  The  facts  which  guided 
him  (and  should  have  guided  us)  to  this  diagnosis  were  {a)  the  presence  of 
slight  abdominal  distention  on  March  i8th  after  five  days  of  partial 
starvation  and  free  catharsis;  (b)  the  occurrence  of  vomiting  in  a  middle- 
aged  woman  who  had  been  ])re\iously  well  and  had  no  special  cause  for 
a  nervous  breakdown;  (c)  the  history  of  periods  of  constipation  alternat- 
ing with  diarrhea;  (d)  the  griping  pain  which,  though  attributed  by  the 
patient  to  the  action  of  cathartics,  did  not  seem  to  Dr.  Codman  explain- 
able thereby. 

Outcome. — After  leaving  the  hospital  April  ist,  she  stayed  at  a 
friend's  house  for  three  weeks;  she  then  returned  to  her  work  as  a  laun- 
dress and  seemed  })erfectly  well  through  May  and  June.  I  inquired 
after  her  this  time  and  noted,  with  great  satisfaction,  her  continued  good 
health,  confirming,  as  I  thought,  my  diagnosis  of  gastric  neurosis.  In 
July  she  had  her  fourth  attack,  which  came  on  this  time  with  great  sud- 
denness. She  was  seen  at  once  by  a  physician  who  found  distention 
and  vomiting,  but  under  his  treatment  she  seemed  well  again  within  a 
few  days  and  resumed  work.  A  few  weeks  later  her  mistress  happened 
to  go  into  the  laundry  and  found  that  Anne  had  a  fifth  recurrence  of  her 
old  trouble — vomiting.  Another  \-acation  was  advised,  but  after  three 
weeks'  rest  at  a  friend's  house  her  symptoms  returned  in  great  force. 
In  this,  the  sixth  attack,  the  vomiting  finally  became  fecal  and  there  was 
intense  abdominal  pain  and  rapid  emaciation.  Dr.  John  T.  Bottomley 
saw  her  in  consultation.     In  answer  to  my  inquiry  he  writes  as  follows: 

"She  presented  a  picture  of  the  terminal  stage  of  an  intestinal  ob- 
struction; distended  abdomen,  anxious  face,  fecal  vomiting,  empty 
rectum,  etc.  A  mass  was  indistinctly  felt  in  the  upper  abdomen  and  was 
believed  to  be  malignant." 

It  seemed  too  late  to  operate  and  the  patient  died  soon  after. 

Diagnosis.— Chronic  intestinal  obstruction,  probably  due  to  malig- 
nant disease. 

Case  346 

Called  at  noon  February  lo,  igio,  to  see  a  Syrian  housewife  of 
twenty-nine  (childless)  whose  groans  and  cries  reached  me  in  the  street 
as  I  came  to  the  house.  I  found  her  writhing  in  intense  pain,  referred 
to  the  epigastrium,  and  accompanied  by  so  much  retching  that  I  could 
hardly  get  her  history  between  the  sj^asms. 


VOMITING  663 

Six  days  previously  she  had  begun  to  vomit  without  obvious  cause — 
the  act  being  immediately  preceded  by  epigastric  pain  and  relieved  by 
emesis.     The  early  morning  was  her  worst  time  in  this  respect. 

Until  this  morning  she  had  slept  well  and  had  suffered  no  pain  between 
the  vomiting  spells,  but  at  5  a.  m.  to-day,  after  a  sleepless  night,  the  pain 
began  again  and  her  vomiting  no  longer  relieves  it. 

Her  bowels  moved  after  an  enema  yesterday,  and  again  this  morning. 

I  examined  her  as  well  as  I  could  between  her  spasms  of  writhing 
and  vomiting.  She  was  a  stout,  flushed,  powerful  woman.  No  percus- 
sion dulness,  no  tenderness  or  muscular  spasm,  no  palpable  mass  could 
be  felt  through  the  belly-walls  by  rectum  or  by  vagina.  The  tempera- 
ture was  97.6°  F.,  the  pulse  100,  the  respiration  30.  The  vomitus 
consisted  of  mucus  and  bile-stained,  watery  fluid.  The  urine  con- 
tained no  albumin  or  sugar.     The  blood  w-as  negative. 

The  woman's  sufferings  seemed  as  intense  as  those  of  acute  perfora- 
tive peritonitis,  yet  I  could  find  no  objecti\c  evidence  of  that  disease. 
The  pain  was  such  as  I  have  seen  in  gall-stone  disease,  yet  until  this 
morning  it  had  been  merely  an  accompaniment  of  the  vomiting — and 
relieved  by  it. 

All  the  complaints  pointed  to  an  abdominal  emergency  of  some  kind, 
yet  I  could  find  none  on  physical  examination. 

Discussion. — I  felt  very  much  puzzled  by  the  case.  The  loudness 
and  vigor  of  her  cries  and  her  healthy  appearance  inclined  me  to  belie\e 
that  she  w-as  free  from  any  serious  disease.  On  the  other  hand,  the 
attending  physician  had  evidently  felt  much  alarmed  about  her.  When 
he  had  previously  telephoned  me  and  found  that  it  would  be  an 
hour  before  I  could  get  there,  he  said  he  was  not  sure  she  would  Vixe  so 
long.  In  the  hullabaloo  going  on  in  the  room  it  was  very  difficult  to 
think,  but  as  I  made  the  effort,  my  eye  roved  about  the  room  and  fell  upon 
the  center  talkie,  which  contained  a  huge  Turkish  hookah,  two  boxes  of 
cigarettes,  and  a  hypodermic  syringe.    The  last  was  the  clue  that  I  wanted, 

Tncjuiry  showed  that  it  belonged  to  the  doctor,  and  that  he  had  given 
morphin  once  or  twice  daily  for  the  last  fwc  days.  As  soon  as  I  came 
to  look  at  the  patient  with  this  in  mind  I  saw  that  her  outcries,  tossing, 
and  thrashing  about  the  bed,  and  her  vehement,  thougii  inchoate  desire 
for  something,  she  knew  not  what,  were  \"ery  characteristic  of  wliat  I 
had  so  often  seen  in  morphin  habitues  deprived  of  their  drug.  ln(|uiry 
showed  that  she  was  not  a  hal)itue,  l)ut  had  acquired  a  strong  need 
for  the  drug  in  fi\-e  days. 

Outcome. — The  subsequent  course  of  the  case  sliowcd  that  tliere 
was  nothinir  else  the  matter  with  her;    her  oriirinal  attack  of  xomiting 


664 


DIFFERENTIAL   DIAGNOSIS 


was  brought  on  by  overeating  and  constipation.  It  had  been  intensified 
and  prolonged  by  the  unwise  use  of  morphin  in  a  neurasthenic.  After 
the  evacuation  of  a  large  fecal  accumulation,  the  withdrawal  of  the 
morphin,  and  a  sensible  diet,  she  recovered  completely,  though  with  a 
good  many  relapses. 

Diagnosis. — Neurosis;  morphin. 


TABLE    XVIII. — VoMlTiNc;.      Signs  and  Symptoms. 


Causes. 

Suggestions  from 
the  history. 

Physical 
examination. 

Vomitus. 

Mode  of  relief. 

„,            .       f                                            History  of  preg- 
loxemia  of  pregnancy  .    .    .    .                  nancy 

Enlarged  uterus. 

Comes  espe- 
cially in  A.  M. 

Diet.     Time. 
Sometimes  emp- 
tying uterus. 

"  Acute  dyspepsia" 

Irritating  food  or 
drink. 

Food  recently 
eaten. 

Starvation  and 
rest. 

Alcoholisin 

Obvious. 

Evidence  of  alco-     I          Odor  of 

Starvation  and 

holism.               I          alcohol.                       rest. 

Obvious. 

Not             j               cf 

characteristic. 

,>  r-    r      ■  ,■  Exposure  to    infec- 

Onset  of  iniectious  diseases  .    .  '^        ■ 


Fever.      Eruption. 
Leukocytosis. 


Postoperative  "shock"     •    .    .  i  Obvious. 


I 
Gastric  neurosis Previous  neuroses. 


.\cute  appendicitis ,     Previous  attacks. 


Right  iliac  spasm 
or  tenderness. 


Not 
characteristic. 


Often  brown 
(changed  blood). 


Not 
characteristic. 


Cardiac  disease 


Evidence  of  cardiac 
disease. 


Failing  heart. 
Stasis. 


Peptic   ulcer  . 


Chronicity. 
Intermittenc 
Regularity. 


Not 
characteristic. 


Not 
characteristic. 


Relieves  pain. 
Often   hyper- 
acid. 


Excess  of 
mucus. 


Time  and 
lavage. 


Reeducation. 


-■Absorption  or 
operation. 


Rest 

Depletion. 
Stimulation. 


Diet  or  opera- 
tion. 


Intestinal   i.liitructi'jn 


Gastric  cancer 


Previdus  attacks 
I    with   constipation. 


Distention.    Vomit- 
ing.     Peristalsis  I V I.       Finally  fees 
Tumor. 


Onset  after  40 


Headache.  Cardia 
tronbles.  Nose- 
bleeds.      Edema. 

Syphilis. 
Lightning  pains. 
I'.ladder  troubles. 


Blood  (occult  I  in  Shows  stasis 

stool.    Gastrectasis.  '  j     r'    '  ,',       , 

,         .  ,.         ,,.  and  oiten  blood. 
.Anaciditv.     1  umor. 


Edema.     -Albumin 

and  casts  in  urine. 

Enlarged  heart. 


No  relation  tt 
food. 


Operation. 


(Jperation. 


])eplcti()n. 
Diet. 


Pupils     Kiu-i-jcrks.  '    No  relatitjii  tc 
.Ankle-jerks  f,H,d. 


Causes  of  Hematuria 


1.  ACUTE  NEPHRITIS' 


2.  CHRONIC     NE- 
PHRITIS 


139 


3.  RENAL  CALCU- 
LUS 


62 


TUMOR  OF 
THE  BLAD- 
DER 


24 


5.  TUBERCULO- 
SIS OF  KID- 
NEY 


19 


KIDNEY 


12 


7.  ACUTE  CYSTITIS 

8.  OXALURIA 

9.  UNKNOWN  I 

CAUSE       / 


78 


'  The  special  limitation-;  of  my  material  make  it  impossible  for  me  to  estimate 
accurately  the  proportion  of  cases  in  which  hematuria  is  a  feature  of  acute  nephritis,  but 
I  believe  it  to  he  the  commonest  type  of  bleeding  from  the  urinary  tract. 


em 


CHAPTER  XX 

HEMATURIA 

The  term  is  applied  only  when  blood  is  visible  in  the  urine  by  the 
unaided  eye.  It  does  not  apply  to  cases  in  which  the  microscope  alone 
enables  us  to  detect  red  corpuscles  in  the  urine.  It  is  also  distinguished 
from  hemoglobinuria,  a  rather  rare  condition,  in  which  the  urine 
contains  free  hemoglobin,  but  no  corpuscles. 

It  is  important  to  make  sure,  before  deciding  that  we  are  dealing 
with  a  case  of  hematuria,  that  all  admixture  of  vaginal  discharges  is 
avoided. 

CAUSES  AND  TYPES  OF  HEMATURIA 

Since  a  very  large  proportion  of  the  varieties  of  hematuria  are  not 
such  as  lend  themsehes  to  the  method  of  differential  diagnosis  by  case 
analysis  which  I  have  used  throughout  this  book,  I  shall  not  be  able  to 
exemplify  them  all  by  discussable  cases  presenting  diagnostic  difficulties. 
I  shall,  therefore,  mention  them  in  more  than  usual  detail  in  this  intro- 
ductory section. 

It  is  convenient  to  divide  the  cases  of  hematuria  into  those  due  to: 

1.  Trauma. 

2.  Nephritis,  acute  or  chronic. 

3.  Renal  disease  (other  than  nephritis). 

4.  Vesical  disease. 

5.  Hemorrhagic  diseases  and  diseases  of  the  blood. 

6.  Poisons. 

7.  General  infections. 

Traumatic  hematuria  is  most  frequently  seen  as  the  result  of  sexere 
crushing  accidents,  as,  for  exam])le,  when  the  body  has  been  run  o\er 
by  a  heavy  wagon.  It  also  occurs  as  the  result  of  injuries  in  the  perineal 
region  and  after  instrumentation.  It  rarely  j)resents  any  diagnc)>tie 
difficulties. 

In  nephritis,  hematuria  freciuentiy  occurs  as  j)art  of  an  acute  jirocess 
w  ilhout  leading  to  any  j)u//.les  in  its  inter])retation.  In  chronic  nephri- 
tis it  may  appear  out  of  a  clear  sky  when  the  underl}"ing  di-ea-e  is  fjuite 
latent,  and  under  tliese  conditions  mistakes  of  diagnosis  often  occur. 


668  DIFFERENTIAL   DIAGNOSIS 

The  best  methods  of  guarding  against  them  will  be  discussed  in  connec- 
tion with  some  of  the  cases  presented  in  the  latter  portion  of  this  chapter. 

Excluding  nei)hritis,  we  have  left  a  group  of  diseases  of  the  kidney 
ordinarily  termed  "surgical,"  and  including — (a)  The  irritations  pro- 
duced by  oxaluria,  with  or  without  gravel,  or  by  stone;  (b)  renal  tuber- 
culosis; (c)  renal  neoplasm;  (d)  cystic  kidney;  (e)  unknown  cause. 
All  these  will  be  exemplified  later,  and,  accordingly,  are  not  further 
discussed  here. 

Vesical  hematuria  may  be  due  to — (a)  Cystitis  of  unknown  origin; 
(b)  stone  in  the  Ijladder;  (r)  tumors,  benign  or  malignant;  (d)  acute 
prostatitis  and  prostatic  hypertrophy;  {e)  tuberculosis  of  the  bladder; 
(f)  the  sudden  and  complete  emptying  of  an  overdistended  bladder,  as 
in  cases  of  acute  retention;  (g)  bilharzia  disease,  w^hich  is  seen  only  in 
tropical  climates  or  in  patients  recently  returned  from  such  a  climate. 
Most  of  these  will  be  discussed  later  on  in  this  chapter.  Bilharzia 
disease  is  recognizable  by  finding  the  eggs  of  the  parasites  in  the  urine. 
When  once  seen,  they  are  easily  remembered. 

The  vesical  Jorms  of  hematuria  are  generally  distinguishable  from 
the  other  types  above  mentioned  because  other  vesical  symptoms,  such 
as  urinary  frequency,  tenesmus,  or  pain,  are  associated  with  the  hema- 
turia. This  rule,  however.  Is  by  no  means  invariable,  since  renal 
tuberculosis  may  produce  marked  vesical  symptoms,  while,  on  the  other 
hand,  bladder  tumors  may  remain  \Aholly  latent  save  for  the  occasional 
presence  of  blood  In  the  urine. 

In  the  hemorrhagic  diseases,  such  as  hemophilia,  scur\-y,  and  the 
various  types  of  purpura,  blood  may  appear  in  the  urine  as  well  as  else- 
where. The  diagnosis  of  the  underlying  condition  is  usually  obvious, 
and  gives  us  a  clue  to  the  explanation  of  the  hematuria.  The  same  is 
true  of  the  hematurias  occasionally  seen  In  connection  with  leukemia 
or  ])ernIcious  anemia. 

A  large  number  of  poisons  occasionally  produce  bloody  urine,  but 
among  the  drugs  which  are  often  used  at  the  present  time  there  are 
very  few  that  lead  to  this  accident.  Cantharides,  turpentine,  and 
phos]jhorus  are  not  often  used  to-day  In  such  doses  as  are  capable  of 
producing  hematuria.  In  factories  where  coloring-matters,  especially 
fuchsin,  are  manufactured,  gases  are  evolved  which  not  Infrcrjucntly 
produce  a  severe  hematuria,  but  o1)vIously  not  many  of  us  are  likely 
to  encounter  cases  of  this  origin. 

In  the  hemorrhagic  forms  of  various  infeclious  diseases  such  as 
typhoid,  typlius,  small-pox,  yellow  fever,  and  septicemia,  blood  Is  occa- 
sionally discharged  with  the  urine,  but  its  origin  Is  usually  clear  enough. 


HEMATURIA  669 


Case  347 


A  housemaid  of  twenty-five,  whose  mother  and  one  uncle  died  of 
consumption,  entered  the  hospital  December  23,  1907.  She  has  had 
bladder  trouble  for  eight  weeks.  She  was  in  the  Boston  City  Hosjjital 
three  years  ago.  Three  months  after  this  time  she  passed  a  tumbler 
of  clotted  blood,  but  was  well  in  a  few  days.  The  same  thing  occurred 
again  in  three  months.  Nine  months  ago  she  again  passed  liquid  and 
clotted  blood  for  three  days,  but  recovered  without  treatment.  Her  last 
attack  was  about  four  weeks  ago,  and,  like  the  others,  was  over  in  three 
days.  The  attacks  have  no  relation  to  the  time  of  menstruation.  Two 
days  ago  she  passed  a  small  clot  and  some  bloody  urine.  After  that  her 
urine  \vas  normal  for  t\\'enty-four  hours.  Yesterday  afternoon  hemor- 
rhage was  again  profuse.  In  these  attacks  she  occasionally  has  a  little 
})ain  during  or  at  the  end  of  micturition.  There  is  no  frequency  of 
micturition,  ])ut  she  passes  urine  twice  in  the  course  of  each  night.  In 
all  other  res])ects  she  feels  perfectly  well. 

Her  physical  examination  is  negative  except  for  some  tenderness 
in  the  lower  jmrt  of  the  a])domen,  especially  on  the  left  side.  The 
leukocytes  are  8000;  hemoglol)in,  75  ]jer  cent.  The  urine  is  not  remark- 
able, exce])t  for  the  presence  of  a  large  amount  of  blood.  An  .v-ray 
of  the  bladder  and  kidneys  showed  no  evidence  of  the  ])resence  of  stone. 
Cystoscopy  showed  that  the  Ijlood  was  coming  from  the  right  kidney. 
Catheterization  of  the  ureters  gave  clear  urine  from  the  left,  nothing 
from  the  right.  There  was  evidence  of  ulceration  here  and  there  in 
the  left  upi)er  portion  of  the  Ijladder.  Rectal  examination  sliowed 
tenderness  in  the  region  of  the  right  ureter  and  in  the  region  of  the 
ulceration  on  the  left  side  of  the  bladder. 

Discussion. — The  essential  feature  of  thi>  case  is  the  intermittent 
hematuria  ])ersisting  for  three  years  in  a  woman  of  twenly-tne  with 
long  intervals  between  the  attacks  and  perfect  health  in  the  interval>. 

By  the  study  of  the  urine  we  ol^tained  no  evidence  of  nephriti,-, 
gcnito-urinary  tuberculosis,  or  litliiasis.  There  are  no  Ijladder  sym])- 
toms  ]K)inting  toward  tumor,  1)enign  or  malignant,  nor  toward  any 
type  of  cystitis.     The  .v-ray  evidence  supports  us  in  excluding  stone. 

Under  these  conditions  cystoscopy  is  ol)\iously  indicated.  ]'>y  the 
coml)ination  of  cystoscopy  and  rectal  exiuuination  we  obiainid  the 
following  additional  infonnation:  that  the  blood  comes  from  the  right 
kidney,  that  the  bladder  is  ulcerated,  that  thi'  ureter  i-  imdtr.  and 
l^robably  stenosed.  These  facts,  together  with  the  family  hi-tory, 
j)oint  di>tinctly  to  tul)ercu]osis  of  thi'  kidney  and  1>ladder.       There  is 


670  DIFFERENTIAL   DIAGNOSIS 

no  other  common  lesion  which  ])roduces  unilateral  renal  hematuria 
with  tenderness,  jjartial  obstruction  of  the  ureter,  and  ulceration  of  the 
bladder-wall. 

In  A'iew  of  this  evidence  it  is  not  necessary  to  delay  the  beginning 
of  treatment  until  a  guinea-pig  can  be  inoculated  with  the  urinary  sedi- 
ment and  allowed  to  ''rijjen"  six  weeks.  This  procedure  should, 
nevertheless,  be  carried  out  at  once. 

Malignant  disease  of  the  kidney,  especially  hypernephroma,  has 
been  known  to  produce  hematuria  lasting  over  a  period  of  three  years. 
But  with  hypernephroma  we  should  not  expect  ulceration  of  the  blad- 
der or  tenderness  of  the  ureter,  and  after  the  lapse  of  three  years  we 
should  expect  local  tumor,  metastases,  and  constitutional  disturbance. 

It  should  be  noted  how  very  good  this  patient's  general  condition 
appears  to  be,  despite  the  apparently  long  duration  of  the  disease.  In 
this  connection  we  may  remember  that  in  the  kidney,  as  in  the  lung, 
tuberculosis  may  pursue  an  entirely  "silent"  and  symptomless  course. 
I  have  recently  seen  the  results  of  such  a  tuberculosis  at  autopsy,  although 
the  j)atient  had  never  had  any  symptoms  remotely  suggesting  any  malady 
of  the  genito-urinary  tract. 

Outcome. — December  28th  the  right  kidney  was  cut  down  upon, 
found  to  be  enlarged  and  cystic,  the  ureter  full,  enlarged,  and  in  |)laces 
constricted.     It  was  removed  together  with  the  kidney. 

The  histologic  examination  of  the  kidney  showed  tuberculosis,  with 
complete  l^locking  of  the  ureter  near  the  kidney. 

The  jjatient  made  an  uneventful  recovery. 

Before  the  operation  a  specimen  of  urine  removed  by  catheter 
(December  i8th)  was  injected  into  a  guinea-pig.  Autopsy,  January 
17th,  showed  tuberculosis  of  the  animal,  and  tubercle  bacilli  were  re- 
covered in  cover-glass  examination. 

Diagnosis. — Tuberculosis  of  the  kidney  and  bladder. 

Case  348 

An  Irish  shop-clerk  of  twenty-eight  entered  the  hospital  March  28, 
igo8.  One  brother  and  one  sister  died  of  phthisis.  For  two  years 
he  has  noticed  frequent  micturition.  Two  months  ago,  for  ]^criods 
lasting  alx)ut  eight  days  at  a  time,  he  passed  bloody  urine  with  clots. 
There  was  some  ])ain  during  micturition.  Ten  days  ago  this  was 
repeated  twice.  There  have  l)een  no  other  symptoms.  He  feels  per- 
fectly well. 

Physical  examination  was  negative,  except  for  some  tenderness  on 
deej)  ])ressure  in  the  right  Hank.     On  the  night  when  he  was  first  seen 


HEMATURIA  67 1 

he  passed  some  urine  entirely  free  from  blood.  The  next  morning  the 
urine  was  excessively  bloody.  X-ray  of  the  kidneys  was  entirely  nega- 
tive. 

The  urine  drawn  by  catheter  showed  the  following  characteristics: 
Amount  in  twenty-four  hours,  26  ounces;  color,  bloody;  specific  gra\ity, 
1023;  albumin,  very  slight  trace;  sediment,  considerable  blood,  normal 
and  abnormal.     Some  pus,  no  casts.     Few  acid-fast  bacilli. 

Cystoscopic  examination  showed  on  the  anterior  wall  of  the  bladder 
a  single  small,  shallow  ulcer  surrounded  by  a  reddened  area. 

Discussion. — The  age  of  the  patient  and  the  duration  of  the  case 
are  against  malignant  disease  of  the  kidney  or  bladder.  The  x-ray 
evidence  tends  to  exclude  stone.  Single  circumscribed  ulcers  of  the 
bladder  are  not  infrequently  due  to  tuberculosis,  and  the  family  history 
supports  this  idea.  Further  certainty  cannot  be  obtained  without  a 
further  study  of  the  urinary  sediment  for  confirmation  of  the  finding  of 
acid-fast  bacilli.  A  guinea-pig  inoculated  subcutaneously  with  35  c.c. 
of  urine  on  the  second  of  April  was  killed  May  nth,  and  showed 
tuberculosis  of  the  lymph-glands,  spleen,  and  liver,  from  which 
tubercle  bacilli  were  recovered.  There  was  no  evidence  of  renal 
disease. 

Outcome. — In  May,  1908,  an  ulcer  of  the  bladder-wall,  apparently 
tubercular,  was  excised.  May  11,  1910,  the  patient's  physician  writes: 
"I  am  more  than  pleased  to  let  you  know  that  Mr.  F.  has  been  feeling 
very  well  since  his  operation.     He  works  every  day." 

Though  positive  evidence  relates  only  to  the  bladder  here,  il  is 
more  than  possible  that  the  kidney  was  also  involved. 

Diagnosis. — Tuberculosis  of  the  bladder.     Renal  tuberculosis? 

Case  349 

A  child  of  four  years  was  first  seen  June  29,  1908.  In  the  ])re\ious 
July  he  fell  off  a  ladder,  after  which  he  was  ])oorly  and  was  thought  to 
have  malaria.  Six  weeks  ago  he  fell  ofi"  an  ex])ress  wagon,  striking  on 
his  left  side  in  the  lumbar  region.  Soon  after  this  he  began  to  i)ass 
bloody  urine,  and  within  the  last  six  weeks  he  has  had  three  such  attacks. 
lasting  each  a  cou])le  of  days;  and  soon  after  his  fall,  >ix  weeks  ago,  a 
lump  was  noticed  on  the  left  side  of  the  abdomen.  It  has  rapidly 
increased  in  size  since  that  time.  The  ])resence  of  this  luni]i.  together 
with  the  fact  that  he  has  fever  every  other  day,  has  led  to  a  dia.L'no-i- 
of  malaria.  He  comes  from  a  \ery  malarious  \illage.  IK'  has  lieen 
ra])idly  losing  weight  for  the  i)ast  six  weeks. 

On  ])hysical  examination  the  child  .^how>  no  anemia  and  no  malarial 


672  DIFFERENTIAL  DIAGNOSIS 

parasites,  but  is  poorly  nourished.  Examination  of  the  head,  neck, 
and  chest  reveals  nothing  abnormal.  The  left  upper  portion  of  the 
abdomen  is  prominent,  and  contains  a  large,  firm,  irregular  mass,  dis- 
tending on  inspiration.  (See  Fig.  180.)  The  air-distended  colon  passes 
in  front  of  the  tumor.  The  edge  of  the  liver  is  felt  two  inches  below 
the  costal  margin,  in  the  nipple-line. 

Discussion. — The  time  of  year  at  which  this  illness  occurs,  the  fever, 
the  age  of  the  child,  and  the  presence  of  the  tumor  which  may  represent 
enlargement  of  the  spleen,  naturally  suggest  malaria,  which  was, 
indeed,  the  diagnosis  at  the  time  when  the  case  was  first  seen.  Malaria 
of  the  se\erer  type  may  be  associated  with  something  resembling 
hematuria,^/,  f.,  with  hemoglobinuria, — but  there  is  no  blood  and  no 
true  hematuria,  only  free  hemoglobin  discoloring  the  urine.  We  must 
have  some  other  explanation,  therefore,  for  the  bloody  urine  in  this  case, 
especially  as  no  malarial  jmrasites  were  found,  despite  careful  search. 

Leukemia  might  give  us  a  similar  clinical  picture,  and  is  not  infre- 
quently complicated  by  hematuria.  That  disease,  however,  could  be 
excluded  in  the  present  case  because  the  stained  blood-smear  was  quite 
free  from  any  suggestion  of  leukemia.  It  is  true  that  leukemia  may  for 
a  short  time  exist  without  a  typical  blood-picture;  under  treatment 
with  arsenic  or  .v-ray  the  blood  may  return  altogether  to  normal,  and 
the  same  change  has  been  known  to  occur  as  the  result  of  a  complicating 
infection  (pneumonia,  erysipelas,  etc.),  or  even  without  known  cause. 
All  these  possibilities,  howe\'er,  are  extraordinarily  rare,  and  we  have 
no  good  reason  to  consider  them  here. 

Large  abdominal  tumors  occurring  in  young  children  are  not  common. 
If  bilateral,  they  are  usually  due  to  congenital  cystic  kidneys;  if  unilateral, 
some  form  of  renal  neoplasm  is  usually  the  diagnosis.  The  other  pos- 
sibilities are  very  few.  In  this  child  there  is  no  reasonable  doubt  that  we 
are  dealing  with  a  new-growth  of  the  left  kidney.  The  hematuria, 
the  tumor,  the  poor  nutrition,  and  the  fever  are  the  usual  features  of 
such  a  disease.  Renal  tuberculosis  is  almost  unknown  in  a  child  so 
young,  and  would  not  have  produced  a  tumor  of  this  size  without  mani- 
festing itself  in  the  urine  by  the  presence  of  pus  and  probably  by  vesical 
irritation. 

Malignant  disease  of  the  kidney  may  be  difRcult  or  im])ossible  of 
diagnosis  in  its  earlier  stages,  before  the  tumor  is  large  enough  to  be 
palpable.  A  metastasis  in  some  distant  organ,  usually  in  some  bone, 
may  be  tlie  first  hint  of  the  renal  neo])lasm.  In  other  cases  we  ha\-e 
long-standing,  intermittent  hematuria,  such  as  we  have  already  exempli- 
fied in  genito- urinary  tuberculosis.     Hiis  is  unfortunate,  because  earlv 


Fig.  i8o. — Outline  plotted  by  pal[)ation  in  a  case  of  intermittent  hematuria  of  a  week's 

duration. 


HEMATURIA  673 

diagnosis  and  early  operation  give  the  only  hope  of  cure.  When  the 
tumor  is  well  marked,  as  in  the  present  case,  the  diagnosis  is  not  usually 
difficult. 

Outcome. — The  child  died  July  19,  1908.     There  was  no  autopsy. 

Diagnosis. — Renal  neoplasm.  (?). 

Case  350 

A  married  woman  of  fifty-two,  a  shoe  stitcher  by  profession,  was  first 
in  the  hospital  in  1905  for  acute  nephritis,  recovering  at  the  end  of  a 
month.  Although  there  were  still  a  very  slight  trace  of  albumin  and  a 
few  fine  granular  casts  in  the  urine  at  the  end  of  her  treatment,  she 
felt  perfectly  well  and  showed  no  cardiac  enlargement. 

She  was  next  seen  November  18,  1907,  complaining  of  hematuria. 
She  has  worked  without  a  vacation  since  her  last  illness,  though  last 
spring  she  fainted  several  times  while  working.  Since  last  May  she  has 
had  much  dyspnea  on  exertion,  and  has  felt  very  tired  most  of  the  time, 
but  has  not  again  fainted.  A  week  ago  the  sight  of  her  left  eye  began 
to  blur.  She  says  that  she  had  similar  trouble  with  her  right  eye 
twelve  years  ago.  She  has  noticed  a  slight  swelling  of  her  ankles  ofif 
and  on  during  the  last  three  months.  Her  aj)petite  has  been  poor,  and 
her  weight  has  fallen  from  187  pounds  last  May  to  119  pounds  at  the 
])resent  time. 

For  the  ])ast  week  she  has  noticed  bloody  urine  and  has  had  cough 
and  ]jain  in  the  chest.     She  has  had  no  headache  or  vomiting. 

On  examination  the  temperature,  ]julse,  and  res])iration  were  normal. 
The  a])ex  of  the  heart  was  in  the  fifth  interspace,  anterior  axillary  line, 
the  action  slightly  irregular,  with  a  tendency  to  gallop  rhythm.  There 
was  a  soft  svstolic  murmur  at  the  aj^ex,  transmitted  to  the  axilla,  and 
the  pulmonic  second  sound  was  accentuated. 

The  bl()od-j)ressure  was  175  mm.  Hg.  A'-ray  of  kidneys  and  Ijladder 
negative.     The  blood  was  negative. 

There  were  many  coarse  and  medium  crackling  rales  scattered  oxer 
both  chests.  Otherwise  they  were  negati\e.  There  was  no  edema. 
The  al)domen  and  extremities  were  a])])arently  normal.  The  urine  wa- 
smoky,  rorr  to  1014  in  specific  gravity;  the  twenty-four-hour  amount, 
from  40  to  50  ounces,  with  albumin  from  o.i  ])er  cent,  to  o.()  ])er  nnt. 
In  the  sediment  were  enormous  numbers  of  fresh  red  cells.  At  iir>i  tlu  iv 
were  no  casts.  Later  on,  moderate  numbers  of  hyaline,  tmr  and  coar-e 
granular  (■a>ts  appeared,  some  with  cells  adherent.  The  hematuria 
ceased  in  ten  days.  .\t  no  time  was  there  any  edema,  heachuhe.  \omit- 
ing,  or  oliguria. 


674  DIFFERENTIAL    DIAGNOSIS 

Discussion. — By  reason  of  the  symptoms  alone  a  diagnosis  Oi 
pulmonary  tuberculosis  had  previously  been  made  in  this  case.  The 
cough,  the  chest  pain,  and  the  emaciation  led  to  this  mistake,  which 
was  easily  rectified  when  the  chart  and  chest  were  examined.  At  no 
time  was  there  any  fever  or  anything  suggesting  the  usual  signs  of 
pulmonary  tuberculosis  in  the  lungs. 

We  had  no  evidence  of  the  ordinary  causes  of  hematuria,  such  as 
stone,  tuberculosis,  or  tumor.  There  was  nothing  to  call  attention 
to  the  bladder  or  to  any  disease,  primary  or  secondary,  in  its  walls. 

The  high  blood-pressure,  the  urine,  and  the  condition  of  the  heart  are 
such  as  we  expect  to  find  in  chronic  nephritis  of  the  glomerulonephritic 
or  interstitial  type,  especially  the  former.  But  we  do  not  ordinarily 
associate  hematuria  with  chronic  nephritis.  It  is  in  the  acute  cases 
that  we  expect  blood.  Nevertheless,  it  has  been  repeatedly  pointed 
out,  as  a  result  of  surgical  experience  within  the  past  ten  years,  that 
the  kidneys  in  chronic  nephritis  may  bleed  profusely  without  any  e^■i- 
dence  of  an  exacerbation  of  the  renal  disease  itself.  Why  this  occurs 
we  have  no  idea,  but  a  number  of  surgeons  ha^-e  proved  the  fact  when 
searching  the  kidney  for  evidence  of  stone  or  other  cause  for  the  hema- 
turia. Doubtless  many  of  the  cases  of  apparently  causeless  hematuria 
belong  to  this  group. 

Outcome. — -The  patient  was  fatigued  on  the  slightest  exertion,  and 
was  very  slow  in  regaining  her  strength.  Considerable  impro\'ement 
took  place,  however,  in  the  course  of  her  two  months'  stay  in  the  hos|)ital. 
Treatment  consisted  of  diet,  with  an  occasional  bitter  tonic. 

Diagnosis. — Chronic  nephritis. 

Case  351 

A  lady  of  seventy,  of  excellent  family  history  and  past  history,  en- 
tered the  hospital  June  25,  1907.  She  has  had  nocturia  (i  to  2)  for 
ten  years.  For  about  a  year  she  has  had  to  pass  water  frequently — /'.  e., 
about  every  two  or  three  hours  in  the  daytime,  and  seven  or  eight  times 
at  night.  During  most  of  this  period  she  has  frequently  noticed  the 
presence  of  fresh  blood  in  her  urine,  together  with  small,  blackish  clots. 
The  urine  has  never  been  foul,  and  there  has  been  no  pain  or  burning 
on  micturition.  There  ha\e  been  periods  of  a  month  or  two  during 
the  past  year  when  she  was  free  from  her  ])rescnt  trouble,  but  for  the 
last  three  months  it  has  been  constant.  She  has  been  graduallv  losing 
weight  for  a  number  of  years,  but  for  the  ];ast  year  her  appetite  has 
been  very  poor  and  emaciation  has  been  rajid. 

On  physical  examination  the  heart's  apex  was  not  seen  or  felt.     The 


HEMATURIA  675 

sounds  were  best  heard  in  the  normal  situation.  There  were  no  murmurs 
or  other  abnormalities.  The  tension  of  the  pulse  was  apparently  in- 
creased, but  the  blood-pressure  was  only  125.  There  were  slight  general 
abdominal  tenderness  and  a  small  umbilical  hernia. 

Several  examinations  of  the  urine  showed  essentially  the  same  condi- 
tions: Amount  in  twenty-four  hours,  30  ounces;  color,  very  dark 
brown;  specific  gravity,  1016;  albumin,  0.3  per  cent.;  bile  and  sugar 
absent;  sediment,  large  amount  of  fresh  blood  with  numerous  round, 
mononuclear  cells,  somewhat  larger  than  the  erythrocytes.  Occasional 
small  macroscopic  blood-clots. 

Vaginal  examination  was  entirely  negative,  as  likewise  was  the  .\"-ray 
of  the  kidneys  and  bladder.  Cystoscoj^ic  examination  showed  ulcerated 
nodules  in  the  wall  of  the  bladder. 

Discussion. — Without  a  cystoscopic  examination  no  diagnosis  is 
i)Ossible  in  a  case  of  this  kind.  From  her  age,  the  urinary  data,  and  the 
bladder  symptoms,  one  might  suspect  bladder  stone  or  malignant 
disease,  but  nephritis,  genito-urinary  tuberculosis,  and  renal  tumor 
would  also  be  {possible. 

Genito-urinary  tuberculosis  is  very  rare  at  this  patient's  age.  The 
urine  would  probably  contain  more  pus  and  less  blood.  Renal  tumor 
^^•ould  probably  be  palpable  after  a  course  as  long  as  that  indicated  by 
this  patient's  history.  The  condition  of  the  heart  and  arteries  is  not 
such  as  we  expect  in  chronic  nephritis.  Acute  nephritis  is  almost 
unknown  at  the  age  of  seventy,  especially  in  the  absence  of  any  infection 
or  ])oisoning. 

K^•en  without  a  cystoscope,  then,  the  diagnosis  of  some  bladder 
trouble  was  rendered  probable  by  the  exclusion  of  renal  disease.  Bladder 
stone  would  probably  produce  more  discomfort  than  this  ])atient  suffered. 
Cystitis  is  not  likely  to  produce  such  long-continued  bleeding.  Tumor, 
tlierefore,  seems  most  ])ro]jable. 

The  ocular  evidence  through  the  cystoscoi)e  left  no  considerable 
doiil)t  as  to  the  nature  of  the  case. 

Diagnosis. — Cancer  of  the  bladder. 

Case  352 

A  l)lameless  cook  of  fifty  years  entered  the  hos])ital  January  1 1 .  kjo;. 
Slie  had  previously  l)een  tliere  in  i8(;6  for  "chronic  cystitis. ""  but  ot 
late  years  she  has  been  \ery  well.  A  year  ago  she  fell  down  >tair-,  and 
although  she  kept  about  and  on  her  feet  after  it,  she  became  xcry  nnuh 
exhausted,  had  pain  in  her  back,  and  had  to  be  sent  to  tlu'  i)0>1on  Cit} 
llosi)ital.     Two   day-    after   arri\ing    there    she    ]ia--e(l    Mood}     urine. 


676  DIFFERENTIAL  DIAGNOSIS 

She  went  home  convalescent  six  weeks  later,  and  has  since  then  been 
very  well. 

Last  Sunday  (five  days  ago)  she  walked  two  miles  to  see  Mrs.  Mary 
Baker  Eddy's  home.  When  she  got  back  her  urine  was  bloody,  and 
she  had  much  pain  on  micturition,  with  tenderness  over  the  bladder 
and  in  the  left  lumbar  region.  She  has  been  passing  blood  ever  since. 
She  is  very  nervous,  and  says  that  her  heart  turns  somersaults.  She 
has  been  steadily  at  work  since  November  ist  the  previous  year.  For 
the  past  three  years  she  has  persevered  in  the  habit  of  reading  in  bed 
until  2  o'clock  in  the  morning. 

Physical  examination  shows  an  obviously  cyanotic  woman,  with 
slight  tenderness  in  the  lower  abdomen,  but  without  any  other  evidences 
of  disease  except  in  the  urine,  which  is  bloody  and  shows  in  the  sediment 
much  fresh  blood  and  triple  phosphate  crystals.  Xo  casts  or  pus. 
During  her  stay  in  the  hospital  the  urine  was  approximately  45  ounces 
in  every  twenty-four  hours,  specific  gravity  from  loio  to  1013,  alkaline 
in  reaction,  with  a  \'ery  slight  trace  of  albumin.  The  colon  bacillus  was 
recovered  in  pure  culture  from  the  urine.  A''-ray  of  the  kidney  and 
bladder  was  negative. 

The  patient  had  numerous  chills,  not  accompanied  by  any  rise  of 
temperature.  The  bladder  was  carefully  sounded  for  stone,  but  none 
was  found.  She  was  gi\'en  urotropin  10  grains  three  times  a  day, 
abundance  of  water,  and  by  the  twenty-first  of  January  the  symptoms 
were  rapidly  clearing  up. 

Discussion. — Such  bladder  symptoms  in  a  woman  of  this  age  are 
often  due  to  renal  tuberculosis,  but  the  alkaline  urine,  without  any 
considerable  amount  of  pus,  without  fever  or  renal  tumor,  incline  us 
to  look  elsewhere  for  the  cause  of  the  symptoms. 

The  low  gravity  urine  and  the  trace  of  albumin,  together  with  the 
age  of  the  jmtient,  lead  us  to  consider  chronic  nephritis  with  one  of 
the  periodic  hemorrhages  already  referred  to  as  an  occasional  complica- 
tion of  that  disease.  Against  this  idea,  however,  is  the  absence  of  any 
cardiac  enlargement  and  the  fact  that  we  can  account  for  the  small 
amount  of  albumin  present  as  a  result  of  the  hematuria  itself. 

The  increase  of  symptoms  following  a  walk,  even  though  It  was  a 
walk  to  the  residence  of  the  founder  of  Christian  Science,  suggests 
bladder  stone  and  led  to  the  careful  investigation  of  the  bladder  by  means 
of  the  sound.  Since  no  stone  was  thus  discovered,  it  did  not  seem 
necessary  to  use  a  cystoscope. 

Bladder  cancer  or  pajiilloma  is  possible,  and  should  the  symptoms 
recur  a  cvstoscopic  search  will  be  indicated. 


HEMATURIA  677 

It  seemed  reasonable  to  try  next  the  therapeutic  test,  based  on  the 
idea  that  we  were  dealing  with  a  cystitis  of  unknown  origin,  and  pending 
the  results  of  animal  inoculation  with  the  urinary  sediment. 

Outcome. — The  sediment  of  the  urine  was  injected  into  a  guinea- 
pig  January  23d.  When  the  animal  was  killed  six  weeks  later  no  evi- 
dence of  the  tuberculosis  was  found.  By  this  time  the  j)atient  was 
convalescent,  the  urine  almost  normal.  On  the  thirtieth  of  January 
she  went  home  apparently  well. 

Diagnosis. — Cystitis  due  to  the  bacillus  coli. 

Case  353 

A  stationary  fireman  forty-nine  years  old  was  first  seen  on  Julv  22, 
1909.  One  sister  died  of  cancer  of  the  stomach;  his  family  history  and 
past  history  are  otherwise  good. 

Twelve  years  ago  his  urine  began  to  be  cloudy  and  occasionally  con- 
tained blood.  At  this  time  there  was  also  pain  at  the  end  of  micturition 
on  various  occasions.  He  had  acute  retention  nine  years  ago,  and 
was  operated  on  at  the  Boston  City  Hospital  by  Dr.  Watson  through 
a  suprapubic  incision.  He  believes  that  he  had  spasm  of  the  neck 
of  the  bladder.  After  seven  weeks  in  the  hospital  he  was  able  to  ])c  at 
work,  but  his  urine  has  e^■er  since  then  been  passed  frc([uently  and  in 
small  amounts. 

At  the  present  time  there  is  no  ])ain.  He  passes  water  about  c\-cry 
two  hours,  and  now  and  then  there  is  blood  in  it.  For  the  past  six 
months  he  has  had  a  j^oor  appetite,  and  has  frequently  vomited  during 
the  day  after  drinking  water.  He  has  also  had  a  great  deal  of  sour 
stomach  and  belching.  Within  the  past  year  he  has  lost  28  })ounds, 
but  he  still  weighs  187. 

There  was  a  systolic  murmur  at  the  a))cx  of  the  heart,  transmitted 
to  the  axilla,  and  associated  with  accentuation  of  the  ])ulmonic  second 
sound,  ])ut  without  cardiac  enlargement.  The  abdomen  sliowcd 
nothing  a])norma].  The  urine  was  very  turl)id,  1)ut  not  at  this  time 
bloody.  The  kidneys  were  not  pal|)aljle.  The  cutaneous  and  >ul)- 
cutaneous  tul)erculin  reaction  was  negati\c. 

Cvstoscopy  showed  a  normal  l)ladder.  Thick  jms  was  seen  coming 
from  the  left  ureter,  while  normal  urine  came  from  the  riglit  ureter. 
A'-ray  of  the  kidneys  and  bladder  was  negative. 

Discussion. — The  case  looks  like  one  of  tuberculous  ki<h"iey.  and 
this  disease  cannot  l)c  ])ositively  exchicU'd.  In  a  ca^e  which  ha>  lasted 
so  long  we  should  expect  a  palpaMe  kidney,  but  a-  we  do  not  know 
with  any  accuracy  the  duration  of  the  di>ea>e,  tlii-  point  i>  not  of  great 


678  DIFFERENTIAL   DIAGNOSIS 

importance.  More  significant  is  the  absence  of  fever,  and  especially 
the  absence  of  tuberculin  reaction.  The  evidence  against  tuberculosis 
could  be  strengthened  by  repeated  search  for  tubercle  bacilli  in  the 
urinary  sediment  and  by  animal  inoculation. 

Hematogenous  infections  of  the  kidney  would  explain  almost  every- 
thing in  the  case  exccjjt  the  hematuria,  but  so  far  as  I  am  aware  hema- 
turia has  not  yet  been  reported  in  connection  with  this  type  of  disease. 

Stones  in  the  kidney  may  be  divided  into  the  "silent"  and  the  "ob- 
streperous"; the  largest  branching  stones  are  often  entirely  latent  and 
symptomless,  discovered  first  at  autopsy  or  by  the  x-ray.  Their  size 
makes  it  very  unlikely  that  they  will  be  overlooked  in  an  x'-ray  plate, 
such  as  was  taken  in  the  present  case.  On  the  other  hand,  the  small 
stones,  such  as  might  be  missed  in  :x;-ray  examination,  are  very  much 
more  likely  to  cause  pain.  In  this  case  w^e  have  no  pain  and  no  rc-ray 
shadows.     Stone  may  be,  therefore,  in  all  probability  excluded. 

What  are  the  other  possible  causes  of  a  unilateral  renal  pyuria,  such 
as  was  here  demonstrated  by  cystoscopy?     I  can  think  of  but  two: 

(a)  Pyonephrosis  of  unknown  origin. 

(b)  Renal  neoplasm. 

Renal  suppuration  with  a  normal  bladder  and  without  tuberculosis 
is  not  common  except  as  a  result  of  hematogenous  infection,  which  I 
have  already  discussed  and  excluded.  Pyonephrosis  of  unknown  origin 
is  usually  intermittent,  like  hydronephrosis,  the  material  accumulating 
for  a  considerable  period  while  a  tumor  gradually  forms,  then  emptying 
with  a  gush  into  the  bladder,  with  disappearance  of  the  tumor.  There 
is  no  history  of  anything  of  this  kind  in  the  present  case. 

Renal  neoplasms  are  not  prone  to  suppurate.  Nevertheless,  we  do 
find  pus  in  varying  amounts  accompanying  the  hematuria  or  alternating 
with  it.     It  is  impossible,  therefore,  to  exclude  neoplasm  in  this  case. 

Outcome. — Operation  August  3d  showed  that  the  left  kidney  was 
converted  into  a  pus-sac,  which  at  the  time  was  thought  to  be  the  result 
of  tuberculosis.  Under  the  microscope,  however,  the  wall  of  the  sac 
showed  the  structure  of  papillary  cystadenoma.  The  kidney  and  ureter 
were  removed.  The  reco\-ery  from  operation  was  satisfactory,  but  the 
patient  soon  passed  out  of  observation. 

Diagnosis.— Papillary  cystadenoma  of  the  kidney. 

Case  354 

An  iron-moldcr  of  forty- two  entered  the  hospital  April  6,  igo6. 
His  uncle  has  recently  dcA'eloped  bloody  urine.  His  wife  has  cancer 
of  the  uterus.     His  ])ast  history  is,  nc\crtheless,  uneventful. 


HEMATURIA  679 

One  month  ago  he  noticed  that  his  urine  was  dark  in  color,  and 
excei)t  for  one  day,  it  has  been  of  this  same  tint  ever  since.  There 
has  been  no  pain  at  any  time,  and  no  other  symptoms.  Xo  clots  or 
gravel  have  been  noticed.  The  color  of  the  urine  \aries  a  good  deal, 
but  is  never  normal.  Cystoscopic  examination  Ijy  Dr.  Lincoln  Davis 
showed  considerable  intravesical  enlargement  of  the  prostate.  The 
bladder  was  normal.  From  the  right  ureter  came  a  jet  of  ]:)Iood  tinged 
fluid,  from  the  left,  normal  urine. 

Except  for  a  mild  secondary  anemia,  physical  examination  was 
otherwise  entirely  negative.  The  blood,  ])ulse,  and  tem])erature  were 
normal.  The  urine  averaged  35  ounces  in  twenty-four  hours,  with  a 
specific  gravity  of  1027  to  1031,  a  large  trace  of  alljumin,  but  no  sugar. 
The  sediment  was  made  u\)  of  normal  blood  and  a  few  leukocytes.  New- 
growth  of  the  kidney  was  thought  to  be  the  most  likely  diagnosis. 

A'-rays  of  the  kidney  and  bladder  were  negatixe.  The  sediment  of 
the  urine  was  repeatedly  investigated  for  tubercle  bacilli,  with  negati\e 
results. 

On  the  eighth  of  A])ril  there  was  no  blood  in  the  urine,  but  on  the 
tenth  it  was  again  present. 

During  these  three  days  urotropin,  10  grains,  was  given  every  eight 
hours,  with  abundant  water. 

Discussion. — As  a  result  of  the  cystoscopic  examination  we  know 
that  the  blood  comes  from  the  right  kidney,  not  from  the  bladder.  We 
ha\e  no  evidence  of  stone  or  of  tuberculosis  in  the  kidney.  The  urine 
and  the  condition  of  the  heart  do  not  suggest  nephritis.  We  find  no 
calcium  oxalate  crystals  or  other  source  of  local  irritation.  Xo  drug 
or  ])oison  capable  of  inducing  hematuria  had  ])een  ingested.  Tlie 
])atient  has  no  form  of  hemorrhagic  or  infectious  disease,  no  aneniia 
or  leukemia,  no  cachectic  condition,  such  as  might  be  complicated  by 
renal  bleeding. 

When  all  these  ])Ossibililies  are  excluded,  as  i>  often  the  case  in 
the  differential  diagnosis  of  hematuria,  two  alternatixes  remain.  We 
may  be  dealing  with  hematuria  due  to: 

(a)  Renal  neoplasm. 

(b)  Unknown  cause. 

It  has  already  been  stated,  in  the  (]i-cii>>i()n  of  a  pre\  i(ni<  ca-e. 
that  diagnosis  of  renal  new-growth>  i>  often  impos>ible  until  the  luuiur 
has  reached  a  considerable  size  or  has  j)roduce(I  nieta-ui>e>.  There 
may  be  months  or  e\'en  years  of  latency  with  nothing  bm  an  (Hea>i()nal 
attack  of  hematuria,  ])erha])s  without  e\en  thi>.  A-  im  tumor  ran  be 
felt  in  this  case,  we  ha\e  no  delinile  rea~~on   for  t!u'  diauno-i-  oi"  new- 


68o  DIFFERENTIAL   DIAGNOSIS 

growth,  but  we  can  by  no  means  be  sure  of  its  absence  except  as  the 
result  of  exploratory  incision. 

A  very  large  number  of  hematurias — perhaps  the  majority  of  them 
all — are  due  to  causes  altogether  unknown  to  us  at  the  present  time. 
After  we  have  distinguished  and  excluded  chronic  nephritis  as  a  cause 
of  otherwise  inexplicable  hematuria,  we  have  left  the  bleedings  due  to 
minute  varices  or  vessels  in  the  renal  pelvis.  In  many  cases  not  even 
these  slight  lesions  can  be  found  when  the  kidney  is  opened  at  opera- 
tion or  at  autopsy.  \'ague  guesses  like  "vicarious  menstruation,"  smart 
phrases  like  "renal  epistaxis,"  do  not  help  us,  and  for  the  present  we  are 
altogether  in  the  dark  regarding  the  cause  of  a  large  group  of  hematurias. 

Outcome. — The  kidney  was  cut  down  upon  April  i8th,  and  found  to 
be  entirely  healthy  both  within  and  without.  A  month  later  the  patient 
wrote  that  he  had  remained  perfectly  well  since  leaving  the  hospital. 

Diagnosis. — -Hematuria,  cause  unknown. 

Case  355 

A  physician  of  forty,  always  previously  well,  was  first  seen  August 
26,  igo8.  About  eleven  that  morning  he  noticed  that  his  urine  was 
bloody.  The  urine  passed  the  night  before  was  normal.  He  has  been 
having  a  cold,  with  some  cough  and  hoarseness  for  six  days,  and  at  the 
onset  of  this  illness  much  headache  and  chilliness.  At  the  present  time 
the  cold  is  practically  gone  and  his  urine  is  exceedingly  clear. 

Physical  examination  of  the  internal  viscera  was  wholly  negative. 

A'-ray  of  the  kidneys  and  bladder  showed  no  stones.  The  urinary 
sediment  consisted  of  blood  with  many  large  calcium  oxalate  crystals. 
On  the  morning  of  the  twenty-seventh  the  urine  was  normal  in  color. 
Later  in  the  day  it  was  again  bloody,  the  amount  of  calcium  oxalate 
\arying  directly  with  the  amount  of  blood. 

Discussion. — In  the  absence  of  fever.  ])yuria,  and  local  bladder 
symptoms,  tuberculosis  seems  here  unlikely.  A  careful  study  of  the 
urine  and  of  the  kidneys  l)y  v-ray  showed  no  evidence  of  stone,  nephritis, 
or  vesical  ])arasitcs  (bilharzia  disease).  Cystoscopy  was  considered,  ])ut 
since  there  were  no  bladder  symptoms  or  other  definite  indications  to 
guide  the  search,  it  was  postponed.  Malignant  disease  of  the  kidney 
and  tuberculosis  were  considered,  but  no  concrete  evidence  could  be 
found  to  supix)rt  either  idea. 

We  were  much  impressed  with  the  close  parallelism  between  the 
degree  of  hematuria  and  the  amount  of  calcium  oxalate  present  in  the 
urine  from  hour  to  hour  and  from  day  to  day.  So  close  was  this  ])aral- 
lelism  that  it  seemed  wise  to  base  treatment  u]X)n  the  idea  that  the 


HEMATURIA  68 1 

calcium  oxalate  might  be  causing  sufficient  irritation  to  produce  the 
hematuria  by  some  means  or  other.  Nevertheless,  we  felt  by  no  means 
convinced  that  this  hypothesis  was  correct,  and  looked  forward  with 
much  interest  to  its  confirmation  or  refutation  through  the  outcome. 

Outcome. — The  patient  was  given  a  diet  from  which  tomatoes, 
spinach,  berries,  cocoa,  tea,  and  pepper  were  excluded.  The  carbo- 
hydrates of  the  diet  w^ere  also  moderately  limited.  Water  was  gi\en  in 
abundance;  also  30  grains  of  sodium  phosphate  before  each  meal.  By 
the  twenty-ninth  of  August  the  bleeding  had  wholly  ceased.  Eighteen 
months  later  there  had  been  no  return  of  the  sjTnptoms. 

Diagnosis. — Renal  irritation  from  oxaluria. 

Case  356 

A  man  of  forty-eight,  who  had  had  lead-poisoning  four  years  before, 
entered  the  hospital  January  21,  1903. 

Eight  years  ago  he  had  an  attack  of  jjain  in  the  region  of  the  right 
kidney  and  thinks  he  passed  a  small  calculus.  Two  years  ago  he 
began  to  notice  blood  in  his  urine,  and  this  was  almost  constant  for  six 
months.  When  it  stop])ed  for  a  day  or  two,  he  usually  had  jjain  o\"er 
the  right  lumbar  region,  relieved  when  blood  reajjpcarcd  in  the  urine. 

In  the  next  six  months  hematuria  came  for  about  twenty  four  hours 
every  week  or  two.  Between  these  attacks  he  had  dull  ])ain  in  the  right 
renal  region,  relieved,  as  before,  by  bleeding.  When  bleeding  occurred, 
he  also  noted  pain  at  the  end  of  the  penis.  He  was  now  losing  strength 
and  had  to  give  up  work.  Hematuria  continued  off  and  on  until  two 
months  before  he  entered  the  hosjntal,  when  it  ceased  altogether.  He 
has  lost  50  ])Ounds. 

Physical  examination  showed  emaciation,  anemia  (hemoglobin,  60 
per  cent.).  Temperature,  gg°  to  101.2'^  F. ;  chest  and  extremities 
normal;  in  the  right  hypochondrium  a  nodular,  insensiti\e  mass, 
extending  q  cm.  below  the  ribs,  descending  with  dee])  inspiration. 
Urine  bloody,  otherwise  normal;   leukocytes,  6500. 

Discussion. — The  renal  pain  makes  it  altogether  proljaljle  that  the 
kidney,  rather  than  the  bkidder,  is  the  source  of  the  hemorrhage.  Tb.e  ]  ire-- 
ence  of  a  palpable  tumor  in  the  renal  region  ])oints  strongly  in  the  -amc 
direction.     Tuberculosis,  stone,  and  neo])lasm  are  tiie  cliief  ])o--il'ilitirs. 

Stone  never  ])roduces  a  tumor  ha\ing  these  charac"teri>tic>:  it  may 
lead  to  a  small  accumulation  of  |)us  and  cheesy  material  in  ilie  rtiiai 
])el\is,  1)ut  not  to  anything  like  the  mass  here  describrd. 

The  emaciation,  the  fever,  and  the  renal  tumor  are  <|uite  eon-i-l(,nt 
with  tuberculosis,  but  we  ex])ect  pyuria.  le>s  profu-e  Meedinu,  and  more 


682  DIFFERENTIAL  DIAGNOSIS 

bladder  symptoms,  such  as  urinary  frequency,  burning,  and  pain. 
Nevertheless,  tuberculosis  cannot  be  excluded  without  cystoscopy  and 
animal  inoculation. 

The  occurrence  of  pain  relieved  by  bleeding  is  distinctly  suggestive 
of  renal  tumor,  also  the  long  duration  of  the  bleeding  without  any  check. 
Indeed,  the  most  prolonged  attacks  of  hematuria  which  we  recognize 
clinically  usually  turn  out  to  be  due  to  renal  neoplasm.  In  nephrolithiasis 
the  bleeding  is  usually  brief,  and  accompanies  the  pain,  instead  of 
relieving  it. 

Outcome. — Operation  showed  a  hypernephroma  which  weighed 
1500  grams,  and  measured  16x14x12  cm.  This  was  successfully 
removed.  Nine  months  later  the  patient  wrote  that  he  was  steadily  at 
work  and  had  gained  40  pounds. 

Diagnosis. — Hypernephroma. 

Case  357 

An  Irish  stableman  of  twenty-eight  entered  the  hospital  August  18, 
1906.     His  family  history  and  past  history  are  negative. 

Two  months  ago  he  noticed  that  his  urine  was  bloody.  He  experi- 
ences a  dull  pain  in  his  back,  more  or  less  constant.  A  considerable 
portion  of  the  time  since  then,  he  has  had  pain  in  the  epigastrium,  in- 
creased by  food,  and  has  vomited  frequently. 

Physical  examination  of  the  chest  and  abdomen  is  negative.  In 
the  right  back,  just  below  the  angle  of  the  scapula,  was  a  tumor  the  size 
of  a  small  English  walnut,  freely  movable  beneath  the  skin,  not  tender, 
and  was  said  by  the  patient  to  be  due  to  a  bullet  which  entered  just 
below  the  right  nipple  in  the  front  and  lodged  in  his  back.  The  patient 
showed  evidence  of  marked  anemia,  the  red  cells  being  3,300,000,  hemo- 
globin, 40  per  cent.,  white  cells,  9000.  The  stained  specimen  showed 
nothing  remarkable  except  achromia.  The  urine  contained  a  large 
amount  of  normal  blood,  but  no  casts.  It  was  sufiEicient  in  amount, 
and  not  abnormal  in  any  other  respect.  Tuberculin  reaction  (cutaneous) 
negative. 

A'-ray  of  the  kidneys  was  negati\-e.  Through  the  cystoscope  blood 
was  seen  spurting  from  the  left  ureter.  There  was  no  evidence  of  trouble 
in  the  bladder. 

Discussion. — Left  renal  hematuria  associated  with  well-marked  sec- 
ondary anemia  occurring  in  a  young  man  who  complains  of  no  bladder 
symptoms  presents  a  clinical  ])icture  distinctly  puzzling  at  the  outset. 
We  have  done  what  we  could  to  rule  out  stone,  nephritis,  calcium  oxa- 
late, and  other  toxic  infectious  and  constitutional  sources  of  hematuria. 


HEMATURIA  683 

Tuberculosis  rarely  produces  so  marked  an  anemia  except  in  ad- 
vanced cases  widi  well-marked  pyuria,  fever,  or  tumor.  Against  tuber- 
culosis we  have  the  absence  of  the  abo\e  signs  and  the  absence  of  a 
tuberculin  reaction. 

Renal  new-growth  is  always  a  danger  threatening  such  patients — 
i.  c,  ])aticnts  with  unexplained  hematuria.  The  nodule  in  the  right 
posterior  thorax  is  not  so  situated  as  to  corres}K)nd  with  any  of  the 
ordinary  sites  for  metastasis  from  a  renal  or  su])rarenal  tumor.  There 
seems  no  good  reason  to  doubt  that  the  patient's  idea  about  the  origin 
of  this  nodule  is  correct.  If  the  case  be  not  one  of  renal  tumor,  we 
ha\e  no  other  plausible  alternative  to  suggest.  Very  jjossibly  it  may 
be  one  of  those  cases  of  "idiopathic"  bleeding  discussed  on  p.  680. 
Further  certainty  can  be  obtained  only  by  ojjeration.  As  the  ])atient 
does  not  seem  to  be  improving  and  has  a  very  considerable  degree  of 
anemia,  exploratory  incision  seems  justified. 

Outcome. — In  the  pelvis  of  the  left  kidney  there  was  found  at 
operation  one  or  two  clots  of  blood.  A  section  of  the  kidney  was  re- 
mo\ed  for  examination  and  showed  absolutely  normal  kidney  tissue. 

Se})tember  2d:  The  patient,  who  had  made  a  good  recovery  from 
the  o])eration,  though  he  still  continued  to  ])ass  considerable  amounts 
of  fresh  blood,  began  to  com])lain  of  stiffness  in  his  neck  and  jaw  muscles, 
with  pain,  and  was  unable  to  open  his  mouth  more  than  an  inch.  Later 
in  the  day  he  began  to  have  convulsions,  and  died  at  9  p.  m. 

Autopsy  showed  ulcer  of  the  stomach,  no  cause  for  hematuria,  and 
nothing  else  of  im])ortance. 

The  results  of  the  autopsy  indicate  that  the  anemia  was  in  all  ]^roba- 
bility  due,  in  ])art  at  least,  to  the  gastric  ulcer.  Our  attention  had  been 
com])letely  diverted  from  this  side  of  the  case  by  the  more  s])ectacular 
sym])toms,  especially  the  hematuria.  In  the  retros])ect  we  say  to 
oursches  for  the  hundredth  time  that  a  major  operation  should  ne\cr  be 
lightly  undertaken. 

Diagnosis. — Gastric  ulcer.     Hematuria;  cause  unknown. 

Case  358 

A  Jewish  schoolboy  ten  years  old  was  seen  October  15,  k^oS.  Ik- 
had  measles  when  he  was  thirteen  months  old.  Six  \\eek>  latrr  lie 
began  to  have  incontinence  of  urine,  which  he  has  had  f\er  >incr.  Vhv 
trouble  is  mostly  nocturnal.  This  morning  his  mother  saw  in  hi>  hrd 
some  bl()(Kl.  which  she  thinks  was  passed  during  tlir  night.  The  l'i>y 
(lid  not  know  it,  but  since  that  time  ha>  continued  to  ]ia--  exi  eetlingly 
bloodv  urine,  with  clots. 


684  DIFFERENTIAL   DIAGNOSIS 

Physical  examination  was  entirely  negative;  the  urine  contained  only 
blood  with  pus  and  large  mononuclear  cells.  Catheter  specimen  remained 
sterile  on  culture-media.  No  tubercle  bacilli  found.  Cystoscopic 
examination  showed  general  reddening  with  areas  of  ulceration.  No 
stone.     The  stream  from  each  ureter  was  clear. 

Discussion. — Sudden  hematuria  occurring  in  a  boy  of  ten  without 
previous  evidence  of  cystitis  is  distinctly  rare.  Stone  in  the  bladder 
was  my  first  thought  after  going  o\er  the  case.  The  renal  causes  of 
hematuria,  such  as  have  been  discussed  in  the  previous  pages,  are  all 
of  them,  very  infrequent  in  children,  with  the  single  exception  of  renal 
new-growth,  of  which  we  had  no  evidence  in  this  case. 

The  results  of  cystoscopy  showed  that  we  had  no  reason  to  suspect 
the  kidney  as  the  source  of  bleeding,  and  indicated  that  we  were  dealing 
with  a  cystitis  of  unknown  origin.  What  may  have  been  the  duration 
of  this  cystitis  we  have  no  means  of  judging;  it  gave  no  signs  of  its  pres- 
ence until  the  day  on  which  he  was  seen,  unless,  indeed,  we  reckon 
the  eight  years  of  nocturnal  enuresis  as  such  a  sign.  I  see  no  good  reason 
for  considering  the  enuresis  in  this  light. 

Outcome. — The  patient  was  given  urotropin,  5  grains  three  times 
a  day.  October  25th  the  urine  was  free  from  blood  and  the  incontinence 
had  almost  ceased.  By  the  first  of  November  he  seemed  perfectly  well 
and  entirely  able  to  control  the  flow  of  urine.  This  improvement  was  sub- 
sequently maintained,  A  guinea-pig  inoculated  with  the  urinary  sedi- 
ment was  killed  seven  weeks  later  and  showed  no  evidence  of  tuberculosis. 

A  point  of  considerable  interest  in  this  case  is  the  sudden  stojjpage 
of  a  long-standing  and  obstinate  enuresis.  Can  we  suppose  that  the 
cystitis  was  of  a  chronic  type  and  represented  the  cause  of  the  incon- 
tinence? It  does  not  seem  probable,  for  at  no  time  had  the  boy's 
symptoms  differed  from  those  of  any  other  case  of  enuresis.  He  can 
hardly  have  had  the  cystitis  since  his  thirteenth  month. 

Another  possible  explanation  presents  itself:  ^lay  it  not  be  that 
the  instrumentation  itself — the  cystoscopy— cured  the  enuresis?  It  is 
a  well-known  fact  that  enuresis  is  prone  to  cease  after  an  o])eration  of 
any  kind,  presumably  because  the  oi)eration  makes  a  strong  impression 
upon  the  child's  gray  matter,  both  cerebral  and  s]jinal.  In  the  present 
case  the  boy  had  no  reason  to  sui)])ose  that  the  c}stosco])y  was  done 
for  the  relief  of  enuresis.  He  knew  that  he  was  being  treated  for  the 
hematuria,  and  that  nothing  was  said  about  curing  the  other  and  older 
habit.  Nevertheless,  he  may  have  drawn  his  own  conclusions  in  his 
own  way — we  cannot  tell. 

Diagnosis. — Cvstitis;  enuresis. 


HEMATURIA 


685 


3    »_' 

3  £ 


3  ^ 


CHAPTER  XXI 


DYSPNEA 


It  is,  on  the  whole,  best  to  maintain  the  usual  distinction  between 
dyspnea  and  polypnea,  and  to  use  polypnea  for  a  quickening  of  respira- 
tion without  any  evidence  of  effort  or  distress,  objective  or  subjective. 
Such  a  polypnea  is  seen  most  often  in  infectious  fevers,  such  as  typhoid 
or  septicemia,  less  often  in  the  terminal  coma  of  diabetes.  In  its  extreme 
form  it  is  to  be  witnessed  in  hysteria,  which  produces  the  most  rapid 
l)reathing  to  be  met  with  clinically. 

Nevertheless,  the  distinction  above  exjjlained  is  neither  so  sharp  nor 
so  logical  as  we  might  desire.  When  a  healthy  man  begins  to  run,  his 
breathing  is  first  cjuickened, — polypnea. — then,  at  the  end  of  a  variable 
period,  it  begins  to  be  slightly  difficult,  until  at  last  true  dysjmea  is 
reached.  So  it  is  in  cases  of  failing  cardiac  compensation,  and  occa- 
sionally in  general  infections  such  as  those  above  mentioned.  In  the 
early  stages  of  the  disease  the  breathing  is  quickened;  later  it  becomes 
difficult  as  well.  We  might  agree  to  say  that  dyspnea  begins  when 
the  accessory  muscles  of  respiration  are  called  into  play.  But  this  is 
rather  an  arbitrary  distinction.  The  movement  of  the  ala  nasi  begins 
in  some  patients  before  the  breathing  has  become  even  distinctly 
quickened,  yet  this  movement  must,  I  suppose,  be  reckoned  among 
those  involving  accessory  muscles  of  respiration. 

For  these  reasons  it  seems  to  me  that  we  can  maintain  the  distinc- 
tion between  dyspnea  and  ]jolypnea  only  as  one  of  convenience,  and  in  an 
approximate  sense. 

Dyspnea  and  short  breath  are  not  always  used  as  equivalents.  Some 
patients  ])uzzle  us  very  much  by  complaining  of  short  breath  desi)ite  our 
inability  to  find  any  sign  of  disease  on  ])hysical  examination.  ]More 
careful  (juestioning  sometimes  Ijrings  out  the  fact  that  by  short  breath 
the  patient  means  a  feeling  of  inability  to  get  as  much  breath  as  he 
thinks  is  owing  him.  His  Ijreathing  may  not  be  quickened  or  difficult, 
but  he  has  the  sense  that  he  cannot  fully  fill  or  distend  his  lungs.  This 
is  complained  of  most  often  by  those  who  are  oxerworked,  underfed,  and 
<hort  of  sleep,  or  who.  for  some  other  reason,  have  allowed  them>clves 
to  get  run  down.  Ikyond  this  I  ha\e  no  idea  of  its  explanation. 
«8(; 


Causes  of  Dyspnea 


1.  EXERTION  AND   EXCITEMENT    |    ^^^^  ^^^  „^^^  ^^^  ^^^  ^^^^^^LY  enumerable 

I        FOR   GRAPHIC   REPRESENTATION. 


2.  INFECTIOUS  DISEASES 


3.  CARDIAC     DIS-1 
EASE  J 


3780 


4.  PHTHISIS 


2037 


5.  CHRONIC 

BRONCHITIS 


913 


6.  PNEUMONIA 


805 


7.  CHRONIC 


HRONIC         ) 

nephritis/ 


718 


8.  ASTHMA 


380 


9.  EMPHYSEMA 


328 


DYSPNEA  689 

Among  the  types  of  difficult  breathing  we  may  distinguish : 

(a)  Inspiratory  dyspnea. 

(b)  Expiratory  dyspnea. 

(c)  Mixed  types. 

The  last  is  by  far  the  most  common,  and  is  seen  in  the  great  majority 
of  uncompensated  cardiac  cases,  in  pneumonia,  pulmonary  tuberculosis, 
and  other  cardiac  and  respiratory  affections. 

Inspiratory  dyspnea  is  comparatively  infrequent,  and  occurs  especi- 
ally as  the  result  of  some  obstruction  in  the  upper  air-passages,  for 
example,  in  laryngeal  diphtheria,  edema  of  the  glottis,  "croup,"  tumors 
of  the  larynx,  foreign  bodies  in  the  larynx,  trachea,  or  primary  bronchi, 
postpharyngeal  suppurations,  Ludwig's  angina,  and  similar  conditions. 
If  the  obstruction  is  below  the  primary  bronchi,  we  do  not  see  dyspnea 
of  this  type. 

Expiratory  dyspnea,  usually  accompanied  by  wheezing  noises,  occurs 
chiefly  in  emphysema  and  asthma,  occasionally  in  pulmonary  edema. 
It  is  apt  to  be  more  or  less  paroxysmal,  whatever  its  cause. 

CAUSES  OF  DYSPNEA 

Heart  disease,  phthisis,  and  pneumonia  are  doubtless  the  commonest 
sources  of  dysj^nea,  but  one  sees  the  slighter  degrees  of  the  condition  in 
a  great  many  anemic  or  debilitated  patients,  perhaps  as  the  result  of  a 
slight  cardiac  insufficiency  not  recognizable  by  other  means. 

Very  acute  and  alarming  dyspnea  is  seen  at  the  onset  of  pneumo- 
thorax, although  both  the  frecjuency  and  the  distress  disappear  altogether 
within  the  course  of  a  few  days  or  weeks  after  the  thoracic  cavities  and 
their  contents  have  adjusted  themselves. 

Occasionally  in  miliary  tuberculosis  one  sees  a  dyspnea  so  extreme 
and  a  rate  so  rapid  that  hysteria  is  sometimes  falsely  diagnosed.  A 
careful  liistory  and  a  thorough  ])hysical  examination  should  set  us 
right. 

Increased  intrathoracic  pressure  due  to  mediastinal  tumors,  to 
aneurysm,  and  occasionally  to  ])ericar(iial  effusion  may  ])roduce  dys])nea. 
sometimes  of  a  ])aroxysmal  ty])e,  which  is  difllcult  to  understand,  since  the 
cause  ])ersists  unclianged. 

A  high  diaphragm  ])us!ied  up  by  ])ressure  from  an  accumulation  of 
fluid  or  gas  or  by  some  solid  tumor  causes  a  certain  amoimt  ot  polypnea, 
and  occasionally  dyspnea,  by  reducing  the  amount  of  space  a\aihible 
for  res])iration. 


690  DIFFERENTIAL  DIAGNOSIS 

THE  EFFECT  OF  POSITION  AND  OF  THE  TIME  OF  DAY 
Probably  for  the  reason  referred  to  in  the  last  paragraph  (high 
diaphragm)  dyspnea  is  always  increased  by  the  recumbent  position 
and  eased  by  sitting  up.  In  extreme  cases  the  patient  leans  forward 
over  his  knees  and  much  prefers  to  sit  in  a  chair,  owing  to  the  cramped 
position  of  his  legs  in  bed.  Mountain-climbers  at  extreme  elevations 
instinctively  assume  a  similar  position  when  endeavoring  to  rest. 

All  types  of  dyspnea  are  apt  to  be  worse  at  night.  This  is  not  wholly 
due  to  the  fact  that  at  night  the  patient  is  usually  trying  to  assume  a 
recumbent  position.  Even  with  bed-ridden  patients,  whose  position 
varies  scarcely  at  all  in  the  twenty-four  hours,  dyspnea  is  much  more 
annoying  after  dark.  This  has  been  explained  by  Hoover  and  others 
as  due  to  the  fact  that  the  respiratory  center  goes  to  sleep  and  allows 
the  respiratory  act  to  become  almost  suspended.  The  patient  then 
wakes  with  a  horrible  gasp.  It  is  in  accord  with  this  theory  that  the 
most  troublesome  dyspnea  of  most  cardiac  patients  is  in  the  earlier 
hours  of  the  night,  when  sleep  is  deepest.  Later  in  the  night  they  can  often 
lie  down  and  get  some  rest. 

CHEYNE-STOKES   BREATHING 

Regularly  recurrent  or  periodic  variation  in  the  depth  and  frequency 
of  respiration,  with  intervals  of  apnea  alternating  with  dyspnea,  receives 
the  name  of  Cheyne-Stokes  breathing.  If  there  is  no  pause  or  apneic 
period,  but  merely  a  rhythmic  quickening  and  slowing  of  respiration, 
the  name  of  Biot's  breathing  is  applied. 

Either  of  these  types  of  breathing  may  occur  in  healthy  infants 
during  sleep.  In  adults  they  usually  complicate  severe  disease  of  the 
heart  or  kidney,  less  often  of  the  brain,  but  also  occur  in  the  more 
critical  stages  of  acute  infectious  diseases,  such  as  pneumonia,  and 
under  these  conditions  may  not  be  the  harbinger  of  death.  In  cardiac 
and  renal  troubles  such  l^reathing  is  a  bad  prognostic  sign,  though  I 
ha\e  known  it  to  occur  during  sleep  for  many  months  before  the  fatal 
termination. 

Case  359 
•  A  German  messenger^boy  of  twenty- two  was  first  seen  February  18, 
1908.  His  family  history  was  negati\e.  Seven  years  ago  he  was  thrown 
from  a  horse  and  tram|)led  on;  his  left  thigh  and  many  of  the  ribs  on 
the  left  side  were  broken.  He  was  in  the  hospital  for  eighteen  months, 
and  states  that  he  was  unconscious  for  the  first  six  months  of  this  time. 
In  December,  1907,  he  was  in  the  Boston  City  Hospital  for  three  days 
on  account  of  a  cough  of  four  days'  duration,  accompanied  by  blood- 


DYSPNEA 


691 


AJC»  0»  «H«S1»CSU 
Hot  i^cAuiev  **^ 


streaked  sputum  and  pain  in  the  left  axilla.  Physical  examination 
was  negative,  and  he  was  discharged  in  three  days.  He  again  entered 
the  same  hospital  on  the  ninth  of  January,  1908,  complaining  of  chest 
pain,  sore  throat,  and  a  slight  cough.  Careful  physical  examination 
and  x-ray  examination  showed  nothing.  Since  that  time  he  has  felt 
weak  and  run  down,  but  has  worked  steadily  up  to  this  morning.  For 
a  week  he  has  noticed  that  his  left  ear  was  not  as  good  as  is  the  right, 
and  for  the  same  period  he  has  had  sensations  of  pinching  on  both  sides 
of  the  chest  near  the  left  nipple, 
and  in  the  neck  a  feeling  as  if  it 
were  being  scraped. 

For  the  past  four  days  he  has  had 
frequent  cough  with  bloody  sputum. 
He  thinks  he  may  have  raised  as 
much  as  half  a  pint  of  blood  in  the 
whole  four  days.  During  this  time 
his  breathing  has  been  very  rapid. 
He  has  been  restless  and  wakeful  at 
night,  and  has  vomited  everything 
that  he  has  taken.  When  on  his 
feet,  he  is  dizzy  and  faint.  He  has 
had  frequent  chilly  sensations,  but, 
so  far  as  he  knows,  no  fever.  This 
morning  while  at  work  he  fainted 
away,  but  walked  .to  the  hospital 
without  assistance. 

On  physical  examination  the 
patient  showed  a  rcmarka]:)ly  rapid 
respiration, — 80  to  the  minute, — 
though  his  pulse  was  only  72,  later 
slowing  down  to  50.  Temperature 
was  99.4°  F.     He  lay  flat  u])on  the 

accident  room  table,  and  seemed  to  be  half  asleep,  except  when  spoken 
to;  then  he  was  nota]:)ly  alert,  answering  all  questions  in  a  strong,  clear 
voice.  There  was  an  occasional  slight,  dry  cough.  The  throat  was 
somewhat  reddened,  the  pu])ils  equal  and  reacting  normally,  the  heart 
absolutely  negative,  the  lungs  slightly  less  resonant  in  the  right  front 
than  in  the  left.  In  the  same  region  the  voice-sounds  are  \ery  slightly 
increased.  Inconstant  bubbling  rSles  arc  heard  in  the  right  front  and 
back.  Physical  examination,  including  the  nervous  system,  blood,  and 
urine,  was  otherwise  entirely  negative. 


Fig.      iSi. — Anesthetic     areas     demon- 
strated in  a  case  of  polypnea. 


692  DIFFERENTIAL  DIAGNOSIS 

During  the  first  week  of  his  stay  in  the  hospital  the  patient's  respira- 
tion continued  at  from  80  to  95  a  minute,  while  his  pulse  was  from  50  to 
60.  His  hands,  arms,  and  lower  legs  were  cyanotic,  congested,  mottled, 
showing  marked  sluggishness  of  the  capillary  circulation.  The  face 
was  flushed,  but  not  cyanotic.  He  was  as  comfortable  when  lying  down 
as  in  any  other  position.     The  fundus  oculi  was  negative. 

Discussion. — Summing  up  the  past  history  of  this  boy,  we  find  two 
sets  of  events,  one  or  both  of  which  may  bear  upon  his  present  dis- 
turbance of  breathing.  The  first  of  these,  however, — the  accident  of 
seven  years  ago, — seems  rather  too  much  in  the  past  to  be  of  any  impor- 
tance in  relation  to  his  present  trouble.  The  pulmonary  injuries  arising 
from  broken  ribs  are  matters  of  immediate  importance  within  a  few 
days  or  weeks  after  their  occurrence,  not  after  the  lapse  of  seven  years. 
Questions  of  this  kind  are  raised  in  connection  with  suits  for  damages 
supposedly  due  to  accidental  injuries,  and  it  is  often  claimed  that  an 
injury  of  this  kind  might  be  the  source  of  long-standing  pulmonary 
disease.  I  do  not  believe  that  there  is  any  sufficient  ground  for  this 
idea. 

The  two  attacks  of  axillary  pain  with  cough  are  very  much  more 
recent,  and  are  probably  connected  in  some  way  with  the  present  trouble. 
Tuberculosis  is  strongly  suggested  by  the  hemoptysis,  as  well  as  by  the 
nature  and  position  of  the  pain  (pleuritic?).  I  have  known  polypnea 
similar  in  many  respects  to  that  here  described,  and  due,  as  it  afterward 
turned  out,  to  miliary  tuberculosis.  This,  indeed,  was  my  first  thought 
in  the  case  here  under  discussion.  The  absence  of  cyanosis,  the  remark- 
ably slow  pulse,  and  the  perfect  comfort  in  the  reclining  position  first 
aroused  our  skepticism,  which  was  further  increased  by  the  nearly 
negative  results  of  physical  examination. 

No  blood  was  expectorated  during  his  stay  in  the  hospital,  and  we 
had  no  independent  account  of  the  fact  of  blood-spitting — only  the 
patient's  own  statement.  The  other  symptoms  complained  of — the 
fainting  and  dizziness,  the  sensory  disturbances  in  the  chest  and  neck, 
the  curious  mental  state,  and  the  mottling  of  the  skin — all  pointed  toward 
a  functional  ner\ous  disturl^ance  as  at  least  a  part  of  the  cause  of  these 
symptoms.  It  will  be  recalled  also  that  he  is  stated  to  have  been 
unconscious  for  six  months  after  his  accident  of  seven  years  ago — a 
condition  strongly  suggest! \e  of  hysteria.  This  hypothesis  accordingly 
was  followed  up  and  led  to  the  additional  observations  recorded  in  the 
outcome. 

Outcome. — It  was  noticed  that  when  actually  talking  to  his  friends, 
his  breathing  slowed  down  to  the  normal,  and  that  any  interruption  or 


DYSPNEA  693 

surprise  would  slow  his  respirations  for  a  few  seconds.  During  the 
night  he  got  but  little  sleep,  but  when  he  dozed  off,  it  was  noted  that  his 
respiration  fell  to  21.  The  patient's  friends  say  that  he  has  been  very 
peculiar  and  untruthful  for  a  long  time. 

The  patient's  bed  was  screened  off  and  he  amused  himself  by  reading. 
When  thus  occupied,  his  breathing  would  at  times  fall  to  normal.  At 
times  his  pulse  was  as  slow  as  45  and  his  respiration  as  rapid  as  100. 
The  patient's  headache  was  entirely  removed  by  an  ethyl  chlorid  spray. 
Areas  of  absolute  anesthesia,  as  shown  in  the  accompanying  diagram, 
were  demonstrated  by  Dr.  Fitz  at  a  clinic.  Half  an  hour  later  the\ 
were  not  present. 

It  was  later  learned  that  he  had  worked  for  a  long  time  in  the  hospital 
at  Baden,  Germany,  and  was  interested  in  medical  subjects;  also  that 
seven  weeks  ago  he  received  news  of  the  death  of  his  father,  the  last  of 
his  immediate  relatives.  Since  then  he  says  he  feels  that  he  has  no  one 
to  live  for.  On  the  twenty-fourth  of  February  it  was  noticed  that  he 
had  no  palatal  reflex.  On  the  third  of  March  he  said  that  he  had 
swallowed  a  safety-pin.  He  did  not  say  whether  it  was  o])en  or  closed. 
X-ray  showed  a  doubtful  shadow  in  his  stomach.  The  patient  said  he 
could  feel  the  pin  in  his  throat. 

At  this  time  the  respiration  became  more  normal  and  remained  so, 
but  the  next  day  he  said  he  could  feel  the  pin  in  the  region  of  the  left 
sacro-iliac  joint.  The  patient  was  dry-cupped  at  this  point,  and  re- 
assured. His  respiration  still  remained  normal,  and  he  was  allowed 
to  go  home. 

In  \iew  of  all  these  facts  we  had  no  hesitation  in  making  the  diagnosis 
of  hysteric  polypnea.  Of  the  four  cases  of  this  disease  which  have  come 
under  my  observation,  three  have  occurred  in  male  ])atients.  In  all, 
the  rajjidity  of  the  breathing  was  greater  than  in  any  but  the  terminal 
stages  of  organic  pulmonary  or  cardiac  disease.  From  these  it  may  be 
distinguished  by  the  following  criteria: 

(a)  Hysteric  poly])nea  is  not  associated  with  any  demonstrabk' 
lesions  of  the  heart  or  lungs;    the  cough  is  generally  very  trifling. 

(//)  The  ra[)i(l  respiration  does  not  continue  throughout  the  twenty- 
four  hours;  it  may  often  ])v  interrupted,  as  in  the  present  case,  \\lHne\er 
the  patient  can  be  led  to  talk  with  interest,  and  fre(|uentlv  cease>  during 
sleej). 

{()  Other  exidences  of  hysteria  are  usuallv  (iinion-tralilc  -  for 
exam])le,  the  susceptibility  to  suggestion,  areas  of  anothe-^ia,  and  wide 
deviations  from  the  truth  which  seem  like  ordinary  lying,  l)ut  are  morr 
])robal)ly  due  to  the  ])eculiar  mental  state. 


694  DIFFERENTIAL  DIAGNOSIS 

(d)  The  distress,  cyanosis,  orthopnea,  and  other  evidences  that 
breathing  is  difficult  (true  dyspnea)  are  absent.  The  breathing  is  rapid 
but  not  labored,  and  its  rapidity  is  usually  much  greater  than  that  asso- 
ciated with  any  organic  disease  of  the  heart  or  lung. 

Diagnosis. — ^Hysteric  polypnea. 

Case  360 

A  collector,  sixty-four  years  old,  was  first  seen  March  10,  1908. 
He  has  had  dyspnea  for  eighteen  months.  For  the  past  four  or  five 
weeks  it  has  become  worse,  and  he  has  slept  every  night  in  a  chair. 
For  two  or  three  weeks  he  has  had  a  cough  with  yellowish  sputa. 

Physical  examination  shows  obvious  loss  of  weight.  The  left  pupil 
is  larger  than  the  right,  and  slightly  irregular.  The  heart's  impulse 
is  in  the  fifth  space,  f  inch  outside  the  nipple.  There  is  no  obvious 
enlargement  to  the  right.  The  action  is  irregular  and  the  sounds  are 
indistinct.  The  second  aortic  sound  cannot  be  heard.  A  coarse,  dis- 
cordant, squeaking  murmur  is  heard  with  systole  at  the  apex,  and  is 
transmitted  to  the  axilla.  At  the  base  there  is  a  rough  systolic  murmur, 
and  along  the  left  border  of  the  sternum  a  low-pitched  diastolic  murmur. 
In  the  third  right  interspace  near  the  sternum  is  a  systolic  thrill.  The 
arteries  are  palpable,  tortuous,  and  show  a  lateral  excursion.  The 
pulses  are  of  small  volume,  low  tension.  There  is  no  capillary  pulse. 
Coarse  bubbling  rales  are  scattered  throughout  both  lungs,  and  there 
is  dulness,  diminished  respiration,  and  fremitus  at  both  bases  behind. 
The  abdomen  shows  dulness  in  the  flanks,  shifting  with  change  of 
position. 

Discussion. — A  long-standing  dyspnea  in  a  man  of  sixty-four 
associated  with  a  cough  which  is  of  A'ery  recent  origin  is  almost  invariably 
due  to  cardiac  disease.  Since  there  are  well-marked  cardiac  lesions 
shown  on  physical  examination,  and  nothing  in  the  lungs  except  what 
is  easily  explained  by  passive  congestion,  it  is  proper  to  assume  that 
the  heart  disease  is  the  cause  of  the  dyspnea,  unless  evidence  is  pre- 
sented suggesting  another  cause. 

A  to-and-fro  murmur  in  the  upper  half  of  the  precordial  region, 
associated  with  absence  of  the  aortic  second  sound,  a  systolic  thrill,  a 
pulse  of  small  volume,  and  moderate  cardiac  enlargement  is  strong 
evidence  of  aortic  disease  with  stenosis  and  regurgitation.  The  diagnosis 
of  aortic  stenosis  is  one  of  those  most  often  made  erroneously.  In  my 
opinion  it  should  never  ])e  made  unless  there  is  also  evidence  of  aortic 
regurgitation — in  other  words,  so-called  pure  aortic  stenosis  probably 
does  not  exist.     At  any  rate,  I  know  of  no  convincing  evidence  of  its 


DYSPNEA  695 

occurrence.     Stenosis  accompanied  by  regurgitation  is  a  proper  con- 
clusion under  two  sets  of  conditions: 

(a)  In  any  case  exhibiting  signs  essentially  identical  with  those  just 
given. 

(b)  In  any  long-standing  rheumatic  case  showing  an  aortic  regurgita- 
tion in  a  person  under  twenty-five,  whether  there  are  physical  signs  of 
stenosis  or  not.  This  latter  conclusion  is  the  result  of  postmortem 
observations.  I  have  never  known  a  case  of  long-standing  heart  disease 
in  a  young  person  in  which  pure  aortic  regurgitation  was  discovered  at 
autopsy.  Stenosis  always  accompanies  it,  because  the  rheumatic  type 
of  endocarditis  does  not  stay  long  upon  the  aortic  vahe  without  produc- 
ing stenosis.  In  older  persons  aortic  regurgitation  without  stenosis  is 
very  common,  and  the  presence  of  a  systolic  murmur  without  the  other 
signs  recorded  in  this  case  should  never  be  considered  as  sufficient 
evidence  for  the  diagnosis  of  stenosis.  In  the  present  case  we  have  all 
the  cardinal  signs. 

Outcome. — Under  rest  in  bed,  with  digitalis  and  purgation,  he 
improved  very  much  within  three  days.  Blood  and  urine  were  normal, 
temperature  constantly  subnormal;  pulse  and  respiration  not  remarka- 
ble. Under  15  minims  of  digitalis  tincture  three  times  a  day  the  patient 
was  able  to  be  up  and  about  by  the  twenty-first.  On  the  twenty-fifth 
digitalis  was  omitted,  and  the  patient  was  able  to  walk  about  without 
distress.  A  half-ounce  magnesium  sulphate  was  still  given  every  morning. 
On  the  twenty-ninth  he  was  allowed  to  go  home. 

Diagnosis. — Aortic  stenosis  and  regurgitation. 

Case  361 

A  school-girl  eight  years  old  was  first  seen  November  19,  1907. 
The  mother  now  has  consumption.  Two  sisters  have  died  of  })ncumonia. 
The  child  had  the  measles  and  chicken-jwx  five  years  ago.  Four  years 
ago  she  visited  the  Boston  Dispensary  and  was  told  that  her  heart  was 
enlarged.  Three  years  ago  she  was  kc])t  out  of  school  for  the  whole 
winter,  and  seemed  about  as  she  is  at  present.  ])ut  ])icked  u])  in  the 
sj)ring.  For  three  weeks  she  has  been  short  of  breath  on  exertion,  and 
has  complained  that  her  feet  were  sore.  In  the  same  period  she  has  been 
growing  })ale  and  thin,  and  has  l)een  heard  to  moan  in  her  sleep.  T\\<t 
or  three  times  in  the  last  four  days  she  lias  coughed  up  a  teaspoonful  of 
blood. 

The  course  of  the  lem])erature,  ])ulse.  and  respiration  are  >een  in 
the  chart  (Fig.  182).  The  child  is  very  i)ale,  thou'^h  her  hemoglobin 
is   75  ))er  cent.      The    ape.x    impulse    is  difiiculi   to  plaee,   but   seems 


696 


DIFFERENTIAL   DIAGNOSIS 


to  be  in  the  sixth  space,  ^  inch  inside  the  nipple-line.  At  the  apex  there 
is  a  palpable  presystolic  and  systolic  thrill.  When  the  child  is  lying 
down,  a  systolic  impulse  can  be  traced  as  far  out  as  the  seventh  space, 
and  nearly  to  the  posterior  axillary  line.  No  left  border  of  dulness  can 
be  marked  out.  (See  Fig.  184.)  Cardiac  pulsation  can  be  felt  over  the 
dull  area  to  the  right  of  the  sternum.  A  loud  to-and-fro  friction  rub 
is  heard  in  the  exposed  space.  (See  Fig.  183.)  In  this  area  the  heart- 
sounds  cannot  be  clearly  made  out.  In  the  anterior  axillary  line  systolic 
and  diastolic  murmurs  are  heard.  Posterior  to  this  point  the  first  sound 
is  very  sharp.  The  right  lung  seems  normal.  The  left  lung  is  hyper- 
resonant  at  the  apex,  but  below  that  dull,  gradually  increasing  to  flatness 


-■v-.--|;7:z: ., .j:j.. :j:7^i:rbT^  .  . .  ^ i,  ;:t:tv::.^;. t^;,^^ 

'«" —     (       M    t   1  r  /   //•   1'/        II    i\  II    l-ii  II  /-'/  /     '         1   1    !'•  l\      '/I  /,  All 

,„.w "..... 

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0-       !   1                     M                     '               i 

lio      i  i       A        1  '  i»     J      ;^     A    '*i        /^  j^     i< 

r;  1     n\         iAi/n.^/i  L-^^-^  A'^  '^^  -^J^ 

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Fig.  182. — Chart  of  case  361. 


at  the  base  behind,  where  the  breath-sounds  are  bronchial,  though 
feeble.  Above  this  many  fine  and  medium  crackles  are  heard.  The 
edge  of  the  liver  can  be  felt  across  the  upper  abdomen,  as  seen  in  the 
diagram. 

Discussion. — As  I  have  definitely  stated  that  a  to-and-fro  friction 
rub  is  audible  in  the  ex[)osed  s])ace,  there  can  be  no  reasonable  doubt 
that  we  are  dealing  here  with  pericarditis.  If  the  friction  were  pleuro- 
]>ericardial  in  origin,  one  would  not  descrilje  it  by  the  words  here  used, 
and  there  would  be  some  note  regarding  its  change  or  disappearance 
when  the  breath  was  held. 

But  acute  serofi'orinous  ])ericarditis  docs  not  cause  dys])nea  unless 


Fig.  183. — Results  of  pal[)ation,  percussion,  and  auscultation  in  a  patient  complaining 
of  three  weeks'  dvsijnca. 


VliS,.   1S4. — Sit^ns  in  hack  (Case  ,>''t).      (Sec  also  I-i^'.   183. 1 


DYSPNEA  697 

the  amount  of  effusion  is  large.  We  see  postmortem  many  a  shaggy 
heart  {cor  villosum)  which  has  developed  as  a  terminal  complication 
in  chronic  nephritis  without  producing  any  dyspnea  whatever.  In  the 
present  case,  therefore,  the  important  question  is:  What  else  have  we 
besides  such  a  pericarditis? 

It  is  to  be  noticed,  in  the  first  place,  that  the  child's  heart  has  been 
known  to  be  enlarged  for  at  least  four  years;  in  the  second  place,  that 
there  is  apparently  decided  enlargement  now,  although  it  is  impossible 
to  say  just  where  the  left  border  is.  There  is  a  double  apical  murmur 
and  thrill  which,  in  itself,  aside  from  the  other  conditions  present, 
would  lead  us  to  suppose  that  the  mitral  valve  was  narrowed  and  incom- 
petent. But  to  any  one  who  has  had  a  considerable  opportunity  to 
verify  his  cardiac  diagnoses  postmortem  it  will  be  an  old  story  that,  in 
markedly  enlarged  hearts,  systolic  and  presystolic  murmurs  at  the  apex 
have  no  diagnostic  value.  They  may  be  present  with  or  without  valvu- 
lar lesions. 

The  observations  of  the  last  ten  years,  especially  in  England,  have 
made  it  clear  that  in  the  heart  troubles  of  childhood  the  whole  heart — 
endocardium,  myocardium,  and  pericardium — is  usually  invohed.  In 
the  inflammatory  process  attacking  the  heart,  the  part  borne  by  the 
valve  is  usually  far  less  important  than  that  borne  by  the  myocardium 
and  the  pericardium.  In  other  words,  j)ericarditis  is  much  more 
common  than  endocarditis  in  the  heart  troubles  which  occur  in  child- 
hood, with  or  without  joint  infection  (rheumatism)  and  chorea.  But 
in  all  cases  the  affection  of  the  myocardium  is  the  all -important  element, 
though  we  have  no  direct  auscultatory  evidence  of  its  changes,  such  as  we 
often  have  when  the  endocardium  or  the  ])ericardium  is  attacked. 

A  ])oint  of  ])ractical  im])ortance  in  these  cases  is  this:  No  matter 
what  murmurs  arc  ])rescnt  we  are  not  l)ound  to  assure  ourselves  or  the 
family  that  an  incurable  cardiac  malady  is  ])resent.  If  only  the  myo- 
cardium has  been  severely  inflamed,  we  may  see  an  almost  complete 
restoration  of  the  cardiac  functions  with  the  disappearance  of  the  mur- 
murs and  a  return  of  the  heart  almost  or  quite  to  its  normal  size.  This 
result,  however,  comes  only  after  months  of  rest  and  careful  watching. 
In  the  great  majority  of  cases  digitalis  docs  harm. 

Outcome. — Under  rest  in  l)e(l,  with  tincture  of  digitalis  5  minims 
every  four  hours,  the  tem])eralure  and  the  friction  rub  gradually  >ul)- 
sided.  After  the  ist  of  December  she  was  carried  out ofdoors  each 
day  and  gradually  improved.  By  the  fifteenth  of  December  the  friction 
rul)  had  disappeared  and  the  sounds  in  the  left  lung  were  reduced  to  very 
slight  dulness  at  the  extreme  left  base,  with  coi/^vheel  re^-iiiration.  but  no 


698  DIFFERENTIAL   DIAGNOSIS 

rMes.  On  the  twenty-first  of  December  the  cardiac  apex  was  in  the 
sixth  space,  3^  inches  from  the  median  line.  There  was  a  palpable 
thrill  and  a  rough  presystolic  murmur,  followed  by  a  loud  systolic  murmur 
at  the  apex.  The  child  could  walk  about  without  dyspnea  and  seemed 
nearly  well. 

In  this  case  presumably  the  mitral  valve  was  attacked,  as  well  as  the 
myocardium  and  the  pericardium. 

Diagnosis. — Infectious  endocarditis,  myocarditis,  and  pericarditis. 
Mitral  stenosis  and  regurgitation. 

Case  362 

A  married  American  woman,  forty-one  years  old,  was  seen  March 
13,  1908.  Her  family  history  and  past  history  are  excellent.  For 
six  months  she  has  noticed  that  she  has  been  short  of  breath.  There 
has  been  no  cough,  no  edema,  no  orthopnea.  For  four  months  she 
has  been  getting  weaker,  but  has  kept  at  work  until  four  weeks  ago, 
when  she  fell  over  at  her  work.  She  was  not  unconscious,  but,  she  says, 
''I  had  no  pulse  and  no  heart-beat  and  they  worked  over  me  for  two 
hours  before  I  was  better."  She  has  been  in  bed  since  that  time,  and 
while  quiet,  feels  well  enough  except  for  a  little  pain  around  her  heart. 
There  has  been  some  bloody  vaginal  discharge  for  a  considerable  portion 
of  the  time  in  the  last  five  years;  there  are  few  days  in  the  month 
without  bleeding,  though  the  amount  is  small. 

Physical  examination  showed  no  anemia  and  nothing  demonstrably 
wrong  in  the  chest  or  abdomen;  normal  urine.  During  the  subsequent 
week  she  had  more  or  less  continuous  bloody  vaginal  discharge,  asso- 
ciated with  slight  anteflexion  and  retroversion  and  a  little  erosion  about 
the  cervix. 

Under  gas  and  ether  on  the  nineteenth  of  March  a  Jet  of  hot  steam 
was  introduced  into  the  uterus,  the  vagina  being  protected  by  a  con- 
tinuous stream  of  cold  salt  solution  passing  around  the  uterine  tube 
during  the  process.  The  steam  was  continued  for  forty  seconds,  and 
after  a  few  minutes'  intermission,  for  thirty-five  seconds.  Following 
this  the  uterine  discharge  ceased. 

Discussion. — The  hyperplastic  endometritis  which  doubtless  was 
present  in  this  case  must  ha\-e  produced  an  undesirable  and  in  some 
ways  debilitating  drain  upon  the  system,  though  it  cannot  have  been 
of  very  great  physical  importance,  since  no  anemia  was  produced.  But 
psychically  such  a  drain  has  a  very  great  effect  on  most  women,  especially 
when  the  knowledge  of  its  presence  is  given  a  solemn  and  ominous 


DYSPNEA  699 

significance  by  the  hints  and  fears  of  kindly  neighbors  who  have  "  seen 
what  such  things  come  to." 

Nothing  in  the  physical  examination  gives  us  any  definite  knowledge 
of  an  organic  disease  to  which  this  dyspnea  may  be  made  secondary, 
but  it  is  a  fact  very  familiar  to  clinicians  that  "short  breath"  is  com- 
plained of  by  a  great  many  patients  in  a  variety  of  debilitated  conditions. 
In  some  of  these  patients  cross-questioning  showed  that  no  true  dyspnea 
is  present,  for  by  "short  breath"  they  mean  not  a  rapid  and  difficult 
respiration,  but  a  certain  sensation  as  if  they  were  unable  to  draw  as 
full  a  breath  as  they  desired.  It  is  thus  a  sensory,  not  a  motor,  phenom- 
enon, and  as  such  should  be  distinguished  from  true  dyspnea.  Just 
what  is  the  significance  of  this  sensation  I  have  no  idea.  One  meets  it 
in  a  great  many  neurasthenic  persons  and  sees  it  pass  off'  under  reassur- 
ance and  work-cure  without  any  change  in  the  condition  of  the  circula- 
tory or  respiratory  organs. 

One  also  sees  a  great  many  cases  of  true  dyspnea  which  are  ne\er 
fully  explained.  The  symptom  is  indeed  much  more  common  than  is 
often  realized,  because  we  often  forget  to  ask  for  it,  and  unless  questioned, 
patients  often  do  not  mention  it.  It  may  be  surmised  that  these  unex- 
plained ty])es  of  dyspnea  are  due  to  mild  forms  of  myocardial  insuf- 
ficiency which  recover  without  our  being  able  to  be  sure  that  they  exist 
or  to  recognize  their  cause.  It  seems  altogether  probable  a  priori  that 
such  types  of  insufficiency  occur  and  that  they  will  assume  greater 
importance  in  the  future. 

One  often  hears  from  patients  the  history  of  an  attack  like  that 
suffered  by  this  woman  four  weeks  ago — an  attack  in  which  a  doctor 
is  called  "and  works  over  the  patient  for  hours  before  she  is  better." 
From  a  considerable  ex])erience  of  the  outcome  of  such  cases  I  have 
come  to  believe  that  this  very  process  of  "working  over  ])coj)le  for 
hours,"  together  with  the  alarm  reflected  from  the  medical  attendant 
to  the  patient  via  sympathetic  relati\es,  is  itself  the  cause  of  most  of  the 
symptoms;  in  other  words,  I  beHe\e  that  these  attacks  are  largely 
hysteric  in  nature,  and  are  much  aggra\ated  by  the  treatment  which 
they  receive.  If  neglected  or  made  light  of,  such  an  attack  will  often 
pass  off  in  a  few  minutes,  but  if  inhalations  of  amyl  nitrite,  alcoholic 
stimulants  by  mouth,  subcutaneous  injections  of  strychnin,  and  heat 
over  tiic  precordia  arc  given,  the  ])aticnt  takes  the  hint,  laces  tlie 
worst  with  courage,  and  proceeds  to  suffer  accordingly. 

Diagnosis. — Hyperplastic  endometritis;  debility. 


■OO  DIFFERENTIAL   DIAGNOSIS 


Case  363 


A  canvasser  seventy  years  old  was  first  seen  April  ii,  1908.  His 
family  history  is  excellent.  Since  his  twentieth  year  he  has  had  epilep- 
tic attacks,  once  in  two  or  three  weeks  at  first,  for  the  past  thirty-five 
years  much  less  frequently.  He  is  unconscious  for  a  few  minutes,  but 
never  falls,  as  he  knows  when  his  attack  is  coming.  He  never  bites 
his  tongue,  and  has  no  incontinence.  Since  his  twentieth  year  he  has 
also  had  involuntary  twitching  of  the  muscles  of  the  left  hand,  for 
which  he  wears  a  glove,  with  relief.  He  denies  venereal  disease.  For 
the  past  month  he  has  had  much  dyspnea,  increasing  within  the  last 
few  days  to  orthopnea,  and  associated  with  a  cough  and  profuse  sputum 
— ^  of  a  cupful  of  thick,  greenish  sputum  in  twenty-four  hours. 

On  j)hysical  examination  the  blood-pressure  is  found  to  be  160  mm. 
Hg;  the  nocturnal  urine  is  more  than  the  diurnal.  Respiration  is  rapid 
and  wheezing;  there  is  a  frequent  loose  cough,  with  mucopurulent  sputum. 
The  heart  shows  nothing  except  unusual  faintness  of  the  sounds  and 
accentuation  of  the  pulmonic  second.  The  chest  is  hyperresonant  on 
percussion  throughout,  obscuring  the  cardiac  dulness.  Expiration 
everywhere  is  prolonged  and  accompanied  by  coarse  squeaks  and 
groans.  The  sputum  contained  many  eosinophiles,  many  mixed 
bacteria,  no  tubercle  bacilli. 

Discussion. — We  have  no  reason  to  doubt  that  this  patient  has 
epilei)sy,  though  there  are  some  symptoms  which  lead  us  to  conjecture 
that  it  may  be  of  the  secondary  type,  and  that  some  source  of  cortical 
irritation  may  be  present.  In  all  probability,  however,  this  long- 
standing malady  has  no  special  connection  with  the  symptoms  from 
which  he  now  is  suffering. 

Dyspnea  combined  with  high  blood-pressure,  nocturia,  and  innumera- 
ble pulmonary  rales  may  be  associated  with  chronic  myocardial  weak- 
ness, with  acute  pulmonary  edema,  or  with  some  pulmonary  infection 
(bronchitis  and  bronchiectasis) .  Presumably  the  heart  is  enlarged  in  this 
case  since  we  find  blood-pressure  high.  If  the  symptoms  had  appeared 
with  great  suddenness  in  a  patient  previously  in  good  condition,  and 
if  the  sputum  had  Ik-cu  very  profuse,  watery,  and  pinkish,  acute  edema 
of  the  lungs  would  be  the  most  ])robable  diagnosis.  But  as  the  onset 
has  been  a  gradual  one,  we  have  no  reason  to  consider  that  mysterious 
and  dangerous  disease. 

It  remains  to  distinguish  between — (a)  Dys])nea  due  to  chronic 
pulmonary  stasis  with  edema,  the  result  of  myocardial  weakness,  and 
(b)   res])iratory   infection.      The   ])ulmonary  hyperresonance  makes   it 


DYSPNEA  701 

impossible  for  us  to  estimate  the  size  of  the  heart;  accurate  ausculta- 
tion is  rarely  possible  when  all  the  sounds  are  obscured  by  noisy  r^les. 
In  cases  of  this  kind,  which  are  very  frequent  in  general  practice,  our 
chief  reliance  must  be  upon  the  pulse.  In  the  present  case  the  pulse 
was  regular,  not  rapid,  or  in  any  other  respect  remarkable.  The  cervical 
veins  showed  no  distention  or  unusual  pulsation.  The  distribution 
of  the  rales  in  the  lungs  was  not  that  usually  seen  in  chronic  edema  due 
to  stasis,  and  the  number  of  bubbling  and  crackling  sounds  was  less  than 
that  usually  heard  in  edema.  The  examination  of  the  sputum  further 
inclined  us  to  believe  that  the  dyspnea  was  due  to  the  condition  of  the 
lungs  rather  than  to  any  form  of  cardiac  insufficiency. 

Putting  together  all  these  facts,  therefore,  it  appears  that  the  dyspnea 
is  due  to  emphysema  and  bronchitis,  with  very  possibly  some  bronchiec- 
tasis as  well.  One  recognizes,  however,  that  the  occurrence  of  such 
infections  is  greatly  favored  in  case  any  weakening  of  the  circulation 
supervenes,  as  it  is  always  prone  to  do  in  men  of  this  age. 

Outcome. — He  was  given  potassium  iodid,  10  grains  three  times  a 
day,  atropin  sulphate  rJ-g-  grain  three  times  a  day,  mor])hin  |  grain 
occasionally  for  dyspnea  and  sleeplessness.  By  the  twentieth  his 
bronchitis  was  nearly  gone  and  he  was  having  good  nights.  He  was 
then  given  a  cough  mixture  in  the  following  recipe  for  cough : 

Codein 3  grains 

Chloroform 15  minims 

Syrup  of  wild  cherry 3  ounces 

A  teaspoonful  of  this  mixture  ever\'  two  hours,  when  needed,  for  cough. 

Diagnosis. — Bronchitis  and  emphysema.    Epilepsy. 

Case  364 

A  housewife,  aged  twenty-six  years,  of  good  family  history,  was  first 
seen  January  i6,  1907.  She  had  never  been  sick  in  bed  until  se\'cntecn 
months  ago,  when  she  had  "typhoid  fever";  at  this  time  she  was  in 
])ed  five  weeks.  Eleven  months  ago  she  had  "bronchitis"  and  was  in 
bed  a  week.  Eight  months  ago  she  had  ])leurisy  with  effusion,  and 
was  tapped,  l)ut  only  about  a  tcasy)oonful  of  clear  lluid  was  drawn  for 
diagnosis.  During  the  past  summer  she  has  been  somewhat  short  ot 
])reath  on  exertion,  with  considerable  wheezing  cough  and  tlic  raising 
of  thick,  greenish  phlegm  in  the  morning.  For  the  ])ast  montli  the 
wheezing  and  rattling  in  her  chest  has  been  almost  constant  and  not 
affected  by  cough.  Dyspnea  has  grown  worse,  and  she  gets  out  of 
breutli  very  easily.     The  wheezing  comes  in  paroxysms  lasting  an  hour 


702 


DIFFERENTIAL   DIAGNOSIS 


about  twice  a  day.  They  are  usually  brought  on  by  exertion  and  are 
relieved  by  rest  or  by  coughing.  She  has  had  no  fever,  no  chills  or  sweats. 
Six  months  ago  she  weighed  112;  now  she  weighs  115  pounds.  She 
feels  well  and  strong,  and  has  not  been  confined  to  bed,  but  complains 
that  any  exertion  brings  on  shortness  of  breath  and  wheezing.  The 
course  of  the  temperature  is  seen  in  the  accompanying  chart. 


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Fig.  185. — Chart  of  case  364. 


The  patient  is  well  nourished,  rather  nervous,  and  fidgety.  Coarse 
rales  can  be  heard  at  some  distance  from  the  chest,  and  the  nostrils 
move  with  each  inspiration.  The  heart's  apex  is  seen  and  felt  in  the 
fourth  space,  5  inches  to  the  left  of  midsternum,  2  inches  outside  the 
nipple.  The  dulness  extends  also  as  low  as  the  sixth  rib.  The  sounds 
are  regular,  of  good  quality,  and  there  are  no  murmurs.  The  condition 
of  the  lungs  is  shown  in  the  diagrams  (Figs.  186  and  187).  The  liver  dul- 
ness extends  three  fingers'  breadths  below  the  costal  margin.  Its  edge  is 
not  felt.  The  blood  showed  a  continuous  leukocytosis  varying  betsveen 
16,000  and  28,000,  with  84  per  cent,  of  polynuclear  cells.  The  urine 
is  not  remarkable.  The  head,  abdomen,  and  extremities  are  negative. 
The  sputum  shows  an  abundance  of  various  bacteria  but  no  tubercle 
bacilli. 

On  the  seventeenth  the  right  chest  was  tapped,  and  40  ounces  of 
fluid  removed,  with  great  relief  to  the  patient.  This  fluid  was  turbid 
and  deposited  a  considerable  whitish  sediment.     It  was  odorless,  1023 


Fig.  iS6. — Results  of  physical  examination  in  Case  364.     (See  also  Fig.  1S7.) 


Fig.  1S7. — ( Iraiihic  rciirescntatioii  of  the  signs  ol.served  in  a  case  i  haiai  tcii/ed  1  i}  dxspnea 
I  eight  months  1  ami   whee/ing  (duc  month '. 


DYSPNEA  703 

in  gravity.  The  sediment  consisted  mostly  of  disintegrated  polynuclear 
cells,  very  few  mononuclears. 

Discussion. — This  case  is  characterized  by  the  occurrence  of 
paroxysmal  dyspnea  and  wheezing,  brought  on  by  exertion  in  a  patient 
who  otherwise  feels  well.  The  physical  examination  indicates  at  once 
that  the  heart  has  something  to  do  with  it.  But  when  we  have  such 
marked  signs  in  the  right  chest,  we  must  always  question  whether  the 
displacement  of  the  cardiac  impulse  is  due  to  hypertrophy  and  dilata- 
tion or  to  the  pressure  of  an  effusion  in  the  right  chest.  Doubtless  the 
heart's  action  is  embarrassed  when  it  is  made  to  beat  in  this  unusual 
position,  even  though  no  cardiac  disease  is  present.  But  until  we 
know  what  is  the  position  of  the  cardiac  apex  after  we  have  tapped  the 
pleural  effusion,  we  have  no  way  of  being  sure  of  any  lesion  in  the 
heart  itself. 

What  is  the  malady  in  the  chest?  The  leukocytosis  indicates  that  it 
is  not  due  to  hydrothorax  or  serous  pleurisy.  The  specific  gravity 
of  the  fluid  obtained  by  tapping  and  the  character  of  the  sediment 
point  to  an  infection  which  will  soon  result  in  frank  pus  (empyema). 

Aside  from  traumatic  cases,  we  recognize  two  types  of  empyema  within 
which  almost  all  purulent  effusions  fall: 

(a)  Postpneumonic. 

(b)  Tuberculous. 

(a)  In  a  considerable  portion  of  the  postpneumonic  cases  the  pneu- 
monia is  so  mild  and  rapid  that  it  is  altogether  unrecognized,  and  the 
empyema  is  supposed  to  be  "primary."  The  study  of  the  fluid,  how- 
ever, almost  always  reveals  pneumococci  more  or  less  degenerated,  and 
on  careful  questioning  we  can  usually  elicit  a  history  that  strongly  sug- 
gests the  original  pneumonia.  Latent  cases  are  especially  common  in 
children.  Practically  all  the  postpneumonic  empyemas  get  \xe\\  and 
stay  well.  Their  prognosis  is  far  better  than  that  of  serous  pleurisy, 
as  I  proved  some  years  ago  by  following  up  the  end-results  of  a  large 
number  of  cases  of  both  diseases. 

(b)  Tuberculous  empyema  has  usually  a  gradual  and  insidious 
onset  like  that  described  in  this  case.  The  fluid  is  often  at  first  serous, 
and  the  doctor  may  blame  himself  (quite  unjustly)  when  it  becomes 
purulent  after  tap])ing.  In  a  minority  of  cases  there  is  obvious  tul^er- 
culosis  of  the  lung  or  |)ncumothorax,  ])receding  the  a])])carance  of  ihc 
em])yema.  Often  there  is  evidence  of  tuberculosis  in  other  organs.  In 
perhaps  the  majority  of  cases,  however,  it  is  the  failure  of  the  empyema 
to  clear  u])  after  drainage  which  first  makes  us  suspect  tuberculosis. 
I  ha\e  never  known  a  tuberculous  case  to  get  well. 


704  DIFFERENTIAL   DIAGNOSIS 

Outcome. — In  the  sediment  of  the  chest  fluid  a  few  small  clumps  of 
tubercle  bacilli  were  demonstrated,  though  none  could  be  found  on  re- 
peated examination  of  the  sputa. 

Though  the  patient  felt  very  well  through  the  later  days  of  January, 
and  was  out-of-doors  daily  in  a  chair,  her  temperature  ranged  higher 
and  higher,  and  on  the  sixth  of  January  a  friction-rub  was  heard  all 
over  the  precordia.  On  the  seventh  the  right  chest  was  again  tapped 
and  a  thicker  and  yellower  fluid  was  withdrawn.  The  patient  was  then 
transferred  to  the  surgical  ward  and  several  pints  of  thick,  odorless, 
creamy  pus  liberated;  specific  gravity  was  1030,  the  sediment  as  before, 
but  containing  no  tubercle  bacilli,  while  pneiunococci  were  easily  culti- 
vated from  it.  For  twelve  weeks  after  this  the  patient  continued  to  run 
a  high,  irregular  temperature,  but  finally  recovered,  and  when  heard 
from  eighteen  months  later,  was  in  excellent  general  health,  though  with 
a  small  discharging  sinus.  A  guinea-pig  inoculated  with  30  cm.  of  the 
chest  fluid  withdrawn  January  17th  was  killed  six  weeks  later,  and 
showed  marked  glandular  tuberculous  lesions,  from  which  tubercle  bacilli 
were  recovered. 

Diagnosis. — Tuberculous  empyema  and  (presumably)  phthisis. 

Case  365 

A  young  woman  of  twenty -two,  a  typesetter  by  profession,  was  seen 
April  3,  1907.  Her  menstruation  has  always  been  irregular,  occurring 
about  every  six  weeks.  Two  years  ago  she  almost  choked  to  death 
while  eating  tea  and  cake.  Ever  since  that  time  she  has  been  very 
short  of  breath  on  walking,  and  suffers  a  gnawing  pain  in  the  left  chest 
and  shoulder  on  any  exertion.  Cold  weather  always  makes  her  worse, 
and  some  days  she  can  scarcely  walk  for  shortness  of  breath.  This, 
howe\er,  never  interferes  with  her  regular  occupation.  She  has  no  other 
s}nmptoms.     Her  appetite,  bowels,  and  sleep  are  normal. 

The  heart's  impulse  and  dulness  reached  to  the  sixth  space,  mid- 
axillary  line,  8  cm.  outside  the  nip])le.  The  right  border  of  cardiac 
dulness  seemed  to  be  at  the  right  sternal  margin.  Cardiac  action  was 
regular,  rapid,  112,  the  first  sound  short  and  valvular,  the  pulmonic 
second  very  much  accentuated.  There  were  no  murmurs  and  no 
venous  pulsation  in  the  neck.  The  pulse  was  of  small  volume,  moderate 
tension.  Blood-])ressure,  115.  The  lungs  were  normal,  save  for  an 
occasional  ])ubl)ling  rale  at  the  left  base.  There  was  a  trilling  edema 
of  the  hands  and  feet,  together  with  marked  coldness.  Blood  and  urine 
showed  nothing  abnormal,  and  there  was  no  indication  of  stippling  in 
the  red  cells. 


DYSPNEA  705 

Discussion. — This  patient's  right  ventricle  seems  to  have  given 
way;  at  any  rate,  the  heart  is  enlarged,  and  the  cause  for  such  an 
enlargement  does  not  appear  to  lie  either  in  valvular  disease,  in 
syphilis,  or  in  any  renal  affection.  Our  problem  is  to  find  some  other 
etiology. 

In  .',  woman  of  this  age  we  can  hardly  suppose  that  we  are  dealing 
with  a  hypertrophy  and  dilatation  due  to  a  chronic  fibrous  myocarditis. 
It  is  true,  however,  that  myocardial  weakening,  with  or  without  demon- 
strable fibroid  changes,  does  occur  in  young  people  as  a  result  of  an 
acute  infectious  disease  of  the  same  type  which  we  call  rheumatism 
when  the  joints  are  invohed.  When  a  heart  is  thus  weakened,  dyspnea 
may  result  either  from  the  gradual  and  progressive  dilatation,  cr  acutely, 
as  the  result  of  some  strain,  such  as  mountain  climbing. 

Chronic  adhesive  pericarditis,  which  may  occur  without  the  patient's 
having  been  aware  of  its  earlier  stages,  often  produces  hypertrophy  and 
dilatation  of  the  heart,  with  resulting  dyspnea.  We  cannot  exclude  this 
disease  in  the  present  patient,  but  there  is  no  definite  evidence  of  it,  no 
retraction  of  Interspaces  in  any  part  of  the  chest  during  systole,  no 
restriction  of  the  normal  cardiac  moljillty  when  the  patient  lies  on  the 
left  side,  no  history  of  acute  pericarditis  in  the  ])ast. 

We  must  beware  of  an  incipient  Graves'  disease  (hyperthyroidism) 
in  any  case  presenting  the  symptoms  here  under  discussion.  The 
cardinal  symptoms  (tachycardia,  thyroid  tumor,  exophthalmos,  tremor) 
may  be  so  slight  as  to  be  easily  o\crlooked,  and  the  cardiac  weakness 
and  enlargement  may  thus  occupy  the  foreground  of  the  clinical  ])icture. 
Some  evidence  of  the  cardinal  sym])toms  must,  however,  be  detected 
before  we  can  go  beyond  a  sus])icion  of  Graves'  disease.  In  this  case  we 
could  find  no  such  e\idcncc. 

Acute  dilatation  of  a  ])reviously  healthy  hr>art  I  have  never  known 
to  occur  except  during  acute  infectious  diseases,  such  as  i)neum()nia, 
})ronchitis,  articular  rheumatism,  or  Intlucnza;  yet  I  have  seen  a  number 
of  cases  like  that  now  under  discussion  in  which  we  had  no  dellnlte 
evidence  of  any  disease  sucii  as  would  weaken  the  myocardium,  and 
were  confronted,  therefore,  with  an  a])])arently  "primary"  dilatation, 
acute  or  subacute.  So  far  I  have  never  followed  such  a  case  to  ]K)st- 
mortcm  examination  without  finding  e\i(lence  of  a  ])re\iou>  myocar- 
ditis. When,  therefore,  we  find  no  causes  such  as  an  acute  infectious 
disease,  hy])erthyr()idism,  or  adherent  j^erlcardium,  and  when  \al\ular 
disease  and  nephritis  can  be  excluded,  1  think  we  should  conclude,  as 
I  do  in  the  present  case,  that  we  are  dealing  with  a  chronic  ir.xocarditis 
of  unknown  origin  (syphilitic  ?j,  with   a  complicating  acute  dilatation. 


7o6 


DIFFERENTIAL   DIAGNOSIS 


Only  by  the  results  of  treatment  can  we  ascertain  whether  the  dilatation 
is  temporary  or  permanent. 

Outcome. — Under  rest,  purgation,  magnesium  sulphate,  and  5 
grains  of  veronal  at  night,  the  [)aticnt  was  remarkably  improved  within 
four  days.  On  the  seventeenth  the  heart  showed  no  enlargement  and 
no  murmur,  and  the  patient  was  able  to  walk  about  without  symptoms. 

No  evidence  of  syphilitic  infection  was  obtained. 

Diagnosis. — Acute  cardiac  dilatation,  cause  unknown. 

Case  366 

A  widow  of  fifty-two  who  had  lost  two  sisters  of  cancer  and  had 
previously  suffered  from  typhoid  fever,  several  attacks  of  pneumonia, 
and  from  one  severe  attack  of  diphtheria  many  years  ago,  was  first  seen 
January  10,  1908.  She  had  several  uterine  operations  four  years  ago,  the 
last  of  which  was  a  partial  hysterectomy.     Three  years  ago  the  left 

kidney  was  removed  on  account  of 
an  injury  to  the  ureter  at  previous 
operation. 

For  three  weeks  she  has  had  a 
cold  in  the  head,  with  sore  throat. 
A  week  ago  she  became  dizzy  and 
almost  lost  consciousness  while  on 
the  street,  but  managed  to  get 
home,  when  she  had  chilliness, 
sweating,  and  i)ains  all  o\'er  her 
body.  Since  that  time  she  has  had 
fever,  dry  cough,  nausea,  and  short- 
ness of  breath.  The  course  of  the 
temperature  is  seen  in  the  accom- 
panying chart.  Her  throat  is  red- 
dened and  swollen.  There  is  herpes 
on  the  nose  and  upper  lip.  The 
glands  at  the  left  angle  of  the  jaw 
are  enlarged.  The  heart-sounds 
are  faint  at  tlie  apex,  but  show  nothing  else  abnormal.  The  heart  is 
not  enlarged.  The  pulse  tension  appears  to  be  slightly  increased. 
There  is  slight  edema  of  the  lower  legs.  The  abdomen  and  the  urine 
arc   negati\'e. 

Soon  after  her  entrance  to  the  hospital  the  patient  had  several  attacks 
of  inspiratory  dysjjnea,  with  a  high  crowing  insj^iration  and  croup}' 
cough. 


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Fig.  iSS. — Chart  of  case  366. 


DYSPNEA  707 

Discussion. — In  all  the  cases  discussed  so  far  in  this  section  the 
dyspnea  has  been  of  the  ordinary  type  seen  in  the  vast  majority  of  cases 
due  to  pulmonary  or  cardiac  disease.  It  has  been  ''mixed" — i.  e.,  it  has 
affected  both  inspiration  and  expiration  alike. 

From  this,  which  is  by  far  the  commonest  type,  we  distinguish: 

(a)  Ins])iratory  dyspnea. 

(b)  Expiratory  dyspnea. 

Expiratory  dyspnea  is  seen  especially  in  emphysema,  in  asthma, 
and  in  the  cases  of  bronchitis  or  bronchiectasis  complicated  by  asthmatic 
attacks.  The  breath  seems  to  go  in  easily  enough,  but  comes  out  with 
a  prolonged  wheeze  and  so  imperfectly  that  the  chest  does  not 
return  to  normal  expiratory  shape  but  remains  in  the  position  of  full 
inspiration. 

Inspiratory  dyspnea,  such  as  was  present  in  the  case  now  under 
discussion,  is  due  always,  so  far  as  I  am  aware,  to  an  obstruction  of  the 
u])per  air-passages — /.  c,  the  pharynx,  lar^Tix,  trachea,  or  primary 
l)ronchi.  The  laryngeal  ty]jes  of  obstruction  arc  Ijy  far  the  commonest. 
Among  these  we  may  distinguish: 

(a)  Ordinary  catarrhal  laryngitis,  which  in  children  is  called 
"croup.'' 

(b)  Diphtheria,  invohing  the  larynx  or  trachea. 

(c)  Tumors  of  the  larynx. 

(d)  Laryngeal  sy])hilis. 

(f)    Paresis  or  ])aralysis  of  the  vocal  cords. 

(/)    Tuberculosis  of  the  larynx. 

Next  in  fre(|ucncy  come  the  causes  which  exert  pressure  upon  the 
trachea  or  ])rimary  bronchi  from  without.  Such  causes  arc  found  in 
tumors  of  the  mediastinum  and  aortic  aneurysm.  Postpharyngeal 
al)sccss,  acute  or  chronic,  produces  a  ])eculiar  ty])e  of  ins])irat()ry  dyspnea, 
with  a  "\vlio()]v'  like  that  of  ])ertussis.  and  a  curious  cough  which 
reminds  one  of  the  bark  of  a  small  ])U])])y  or  the  cry  of  some  bird  (" rri 
(h'  cananr'').  I  ha\e  heard  such  a  sound  again  and  again  echoing 
through  the  lialls  of  an  ()ut-])atient  department,  and  seldom  found 
myself  wrong  in  the  "sna])  diagnosis"  of  ])ostpharyngeal  abscess. 

Sy])hilitic  stenosis  of  a  bronchus  may  ])roduce  inspiratory  dys])nea 
of  a  paroxysmal  type,  which  precisely  simulates  1)ronchial  astluua. 

In  tlie  i)resent  case  we  ha\e  reason  to  susjiect,  in  adxance  of  an 
accurate  diagnosis  by  means  of  tiie  laryngosco])e,  that  acute  hiryngitis 
will  l)f  found  l)ecause  the  ])atient  has  exidently  bem  iinadcd  1)\'  an 
acute  infection  in\()l\ing  tlie  up])er  air  i)as>age>.  Siuh  an  infection 
verv  conmionlv  reaclie--  the  'arvnx.     Xotliin;/  more  can  he  ^aid   until 


7o8  DIFFERENTIAL   DIAGNOSIS 

the  larynx  is  thoroughly  examined,  but  we  have  no  reason  for  suspecting 
any  of  the  other  causes  listed  above. 

Outcome. — Tracheotomy  instruments  were  kept  at  hand,  and 
inhalations  of  steam,  with  a  laryngeal  spray  of  Dobell's  solution,  used 
at  frequent  intervals.  Wine  of  ipecac,  i  dram,  was  given  several  times 
with  relief  when  laryngeal  dyspnea  became  extreme.  It  was  later 
noticed  that  the  palatal  reflex  was  entirely  absent.  Subsequent  ex- 
amination of  the  throat  and  larynx  showed  a  very  marked  atrophic 
rhinitis,  with  acute  laryngitis  and  tracheitis.  The  patient  continued 
very  hoarse  until  the  twenty-eighth  of  January,  though  the  lungs  were 
nearly  clear  by  the  nineteenth.  By  February  5th  the  patient  was  able 
to  go  home. 

Diagnosis. — Acute  laryngitis. 

Case  367 

A  school-girl  of  six  was  first  seen  November  29,  1907.  About  an 
hour  before  her  entrance  she  was  seized  with  cough,  frontal  headache, 
vomiting,  and  rapid  breathing.  Previous  to  that  time  she  had  been 
perfectly  well,  as  far  as  her  mother  knows.  The  child  looked  healthy, 
but  breathed  very  rapidly  and  with  a  pronounced  inspiratory  wheeze. 
The  tonsils  were  large  and  injected.  On  account  of  gagging  further 
examination  was  impracticable.  There  was  frequent  brassy  cough. 
The  breathing  was  everywhere  normal.  White  cells  were  15,500; 
urine,  negative.  Physical  examination  was  otherwise  entirely  negative. 
After  a  teaspoonful  of  wine  of  ipecac  the  dyspnea  promptly  ceased. 
Next  day  the  child  was  well. 

Discussion.— This  case  is  included  merely  to  show  what  I  mean, 
and  what  I  think  most  physicians  mean,  by  "croup."  Since  we  have 
come  clearly  to  distinguish  the  cases  of  laryngeal  diphtheria  which  were 
formerly  mistaken  for  "croup,"  some  clinicians  have  been  inclined  to 
assume  that  the  familiar  clinical  entity  which  for  generations  has  passed 
under  that  name  was  abolished.  The  reason  for  retaining  the  name 
is  that  in  children  acute  laryngitis  is  apt  to  appear  at  night  suddenly, 
and,  as  it  were,  out  of  a  clear  sky,  and  to  terminate  abruptly  before 
morning,  while  in  adults  the  clinical  picture  is  quite  different  because 
the  laryngitis  aj)pears  and  disappears  so  much  more  slowly. 

This  difference  is  due,  doubtless,  to  the  accumulation  of  adenoid 
tissues  about  the  throats  of  children  and  its  subsequent  disappearance 
in  adults. 

Diagnosis. — Croup. 


DYSPNEA  709 


Case  368 


A  barrel-maker  of  twenty-three,  whose  family  history,  past  history, 
and  habits  are  good,  was  seized  two  weeks  ago  with  headache,  vertigo, 
and  vomiting.  Despite  these  symptoms  he  managed  to  work  until  a 
week  ago,  when  he  began  to  be  markedly  short  of  breath.  In  the  past 
two  days  he  has  had  considerable  cough  and  scanty  yellow  sputa.  The 
patient  mentions  no  other  complaints. 

On  physical  examination  the  cardiac  apex  is  in  the  fifth  space,  i| 
inches  outside  the  nipple-line.  The  right  border  corresponds  with  the 
right  sternal  margin.  The  aortic  second  sound  is  accentuated.  Blood- 
pressure  is  175  mm.  Hg.  The  arteries  show  no  sclerosis.  The  chest  is 
everywhere  hypcrresonant,  expiration  prolonged  and  difficult,  accom- 
panied by  innumerable  squeaks  and  bubbling  sounds.  The  abdomen 
is  distended  and  shows  shifting  dulness  in  the  flanks. 

The  temperature,  pulse,  and  respiration  were  normal  for  ten  days. 
The  white  cells  on  the  twenty-sixth  were  16,000;  after  two  days  of 
treatment  they  had  fallen  to  5000;  hemoglobin,  60  per  cent.  The 
urine  averaged  20  ounces  in  twenty-four  hours,  ici6  in  sj)ecific  gravity. 
A  large  trace  of  all^umin  was  found,  and  very  many  hyaline  and  granular 
casts,  with  much  fat  adherent. 

Discussion. — As  the  dyspnea  is  here  associated  with  cardiac 
enlargement,  it  is  proper,  first  of  all,  to  inquire  whether  cardiac  disease 
is  its  cause.  We  find  no  evidence  of  valve  trouble.  Fibrous  myocarditis 
is  not  common  at  this  age.  Acute  dilatation  is  a  diagnosis  which  we 
make  only  as  a  last  resort  when  no  trace  of  any  cause  can  be  found. 
Adherent  ])ericardium  cannot  be  ruled  out,  but  has  no  definite  facts  in 
its  favor.     We  ha\e  no  evidence  of  inci])ient  hyj)erthyroidism. 

The  high  blood-pressure  makes  us  sus])cct  the  kidney,  and  as  soon 
as  we  turn  our  attention  to  the  condition  of  the  urine,  we  percei\e  that 
its  characteristics  arc  not  those  ordinarily  associated  with  heart  disease 
and  renal  congestion.  I  have  known  l)ut  two  cases  of  ])assi\e  renal 
congestion  with  a  urine  of  low  gravity.  The  opj)osite  is  the  almost 
in\arial)le  rule. 

Nephritis,  then,  is  in  all  ])robability  the  cause  of  the  dyspnea  and 
the  other  sym])toms,  Init  what  type  of  nephritis  is  it?  Certainly  not 
acute  ne])hritis.  since  the  heart  is  hypertro])hied.  Probably  not  chronic 
interstitial  ne])hritis,  since  this  disease  is  rare  at  t^\■enty-three  and  is 
not  often  associated  with  any  considerable  degree  of  anemia.  In  all 
y)robability  we  are  dealing  with  the  chronic  glonu'riilonej>hritis  of  Coun- 
cilman and  \\'riuht,  the  secondarv  contracted  ki(lnr\  of  tlu'  (lermans. 


7IO  DIFFERENTIAL   DIAGNOSIS 

Outcome. — The  patient  was  gi\en  magnesium  sulphate,  2  ounces, 
at  the  time  of  entrance,  and  ih  ounces  every  morning  thereafter;  also 
hot-air  bath  every  second  day.  His  liquids  were  limited  to  two  pints 
daily,  and  his  diet  was  restricted  as  for  acute  nephritis.  Under  this 
treatment  his  tormenting  headache,  his  nervousness,  and  edema  dis- 
appeared in  four  days.  His  dyspnea  persisted  three  days  longer,  but 
was  not  marked  after  four  days.  The  dimensions  of  the  heart,  how- 
ever, showed  no  change.  He  was  allowed  to  finish  his  convalescence 
at  home  after  the  fifth  of  October,  the  diet  no  longer  restricted. 

Diagnosis. — Chronic  glomerulonephritis. 

Case  369 

An  electrician  of  sixty-two,  with  an  excellent  family  history,  past 
history  and  habits,  entered  the  hospital  November  12,  1907.  He 
had  been  perfectly  well  until  he  began,  nine  months  ago,  to  suffer  from 
shortness  of  breath.  Two  months  ago  the  dyspnea  compelled  him 
to  quit  work  for  two  weeks,  and  a  month  ago  he  had  to  give  up  for  good. 
At  times  he  has  been  unable  to  lie  down  at  night.  There  has  been  a 
slight  cough,  with  a  little  grayish  sputum.  He  has  slept  very  poorly, 
and  has  sweated  much  at  night  during  the  past  week.  Two  years  ago 
he  suffered  for  five  or  six  weeks  from  quite  marked  edema  of  the  legs 
at  night-time,  entirely  without  any  other  symptoms.  For  years  he  has 
risen  once  at  night  to  pass  water. 

The  patient  was  orthopneic  at  entrance.  The  heart's  apex  was  in 
the  fifth  interspace,  one  inch  outside  the  nipple,  the  right  border  i\ 
inches  to  the  right  of  the  sternal  margin.  The  heart's  action  was  slightly 
irregular'  with  a  slightly  accentuated  pulmonic  second  sound.  There 
were  no  murmurs.  Blood  and  urine  showed  nothing  abnormal.  There 
was  no  edema  or  hydrothorax.  The  edge  of  the  liver  was  felt  almost 
on  the  level  of  the  navel.  There  was  dulness  and  diminished  breathing, 
voice,  and  fremitus,  with  coarse  bubbling  rales  below  the  angle  of  each 
scapula.  Temperature,  pulse,  and  respiration  were  normal  throughout 
his  stay.  The  sputa,  twice  examined,  showed  a  variety  of  bacteria, 
but  no  tubercle  bacilli. 

Discussion. — This  case  exemplifies  a  type  extremely  common  in 
general  practice.  Since  the  urine  is  normal  and  the  blood-pressure 
apparendy  not  elevated,  we  ha\e  no  good  reason  to  suspect  that  com- 
monest cause  of  dyspnea  and  edema  in  elderly  men — chronic  interstitial 
nephritis.  The  examination  of  the  heart  gives  us  no  reason  to  ])clicve 
that  the  trouble  originates  in  disease  of  the  valves  or  of  the  pericardium. 
We  have  no  chronic  pulmonary  disease  which  might  weaken  the  heart, 


DYSPNEA  711 

especially  the  right  ventricle,  in  the  attempt  to  force  blood  through 
capillaries  decimated  by  emphysema  and  chronic  pneumonitis. 

Only  one  alternative  remains  so  long  as  our  present  conceptions 
of  circulatory  disease  are  adhered  to.  The  myocardium  must  be  insuf- 
ficient. What  the  nature  of  this  insufficiency  is  seems  to  me  wholly 
problematic.  We  can  no  longer  assume,  as  of  yore,  that  a  demonstra- 
ble fibrous  myocarditis  underlies  the  insufficiency  of  the  heart  muscle. 
It  has  been  abundantly  proved  that  we  may  have  fatal  myocardial 
insufficiency  without  fibrous  myocarditis;  also  that  we  may  ha\'e  exten- 
sive myocarditis  without  any  cardiac  weakness.  The  same  thing  is 
true  of  the  microscopic  forms  of  myocardial  change:  they  are  \ery 
common  both  with  and  without  the  clinical  evidences  of  myocardial 
weakness,  but  we  have  no  reason  to  assume  that  they  are  its  cause. 

The  modem  studies  of  defecti\e  conduction  in  cardiac  impulses 
may  in  time  give  us  the  key  to  our  difficulty,  but  for  the  present  we  must 
state  our  diagnoses  in  functional  or  physiologic  terms.  When  con- 
fronted with  a  case  like  that  above  narrated,  our  diagnosis  should  be 
myocardial  weakness  or  myocardial  insufficiency,  not  myocarditis. 

Outcome. — Under  rest  in  bed,  with  J  grain  of  morphin  at  the  time 
of  entrance,  magnesium  sulphate,  i  ounce,  every  morning,  -^V  grain 
strychnin  three  times  a  day,  the  heart  became  more  regular,  stronger, 
and  a  well-marked  systolic  murmur  ajjpeared  at  the  a])ex.  By  the 
seventeenth  the  edema  had  gone  from  the  lungs,  and  the  patient  was 
well  as  long  as  he  avoided  any  exertion. 

Diagnosis. — Myocardial  insufficiency. 

Case  370 

A  Russian  carpenter  of  thirty-four,  ne\er  pre\"iously  sick,  was  first 
seen  December  22,  1906.  While  lifting  a  hea\"y  ])iece  of  timl^er  four 
months  ago  he  felt  something  "give  way  in  his  chest."  He  was  carried 
home  and  has  not  worked  since,  owing  to  dysjmea  on  the  slightest 
exertion,  pal])itation,  and  dry  cough.  He  needs  three  or  four  ])illo\\ > 
at  night,  and  slee])s  poorly.  His  a])pctitc  and  ])owels  are  normal.  He 
has  no  urinary  symptoms.  Des])ite  treatment  his  symptoms  increased 
four  days  ago  and  he  has  had  com])letc  ortho])nca  and  steady  pain  under 
the  right  costal  margin.  There  has  ])ecn  no  edema  of  the  feel  at  any 
lime.  Dyspnea,  cyanosis,  engorgement  of  the  eer\ical  \eins,  were  the 
striking  features  at  entrance.  The  heart's  ini])ulse  was  seen  and  felt 
two  inches  outside  the  ni])ple  in  the  sixth  inters] lace.  There  was 
delirium  cordis.  .\  systolic  murmur  was  heard  at  the  apex  and  in  the 
axilla.     The  first  sound  was  \erv  sharp,  and  oeca-ionallv.  perhai^^  one 


712 


DIFFERENTIAL    DIAGNOSIS 


beat  in  every  four  or  five,  was  preceded  by  a  short  presystolic  roll.  The 
pulmonic  second  sound  was  accentuated  and  double.  There  were 
many  more  beats  audible  at  the  apex  than  palpable  at  the  wrist.  (See 
chart.)  There  were  many  fine  bubbling  rales  at  the  base  of  both  lungs, 
and  slight  dulness  at  the  right  base.  The  tender  edge  of  the  liver  was 
felt  two  inches  below  the  costal  margin  in  the  nipple-line.    The  upper 

border  of  the  organ  was  in  the  fourth 
interspace.  Blood  and  urine  were 
normal.     No  ascites. 

In  the  chart  (Fig.  189)  the  line  be- 
low that  representing  the  temperature 
stands  for  the  number  of  heart-beats. 
Just  below  this  is  the  radial  pulse 
curve. 

Discussion. — The  kidney  seems  to 
be  all  right;  the  heart  is  obviously  dis- 
eased. It  is  there  that  we  should 
look  first  for  the  cause  of  the  dyspnea. 
Apparently  it  is  the  right  ventricle 
which  is  laboring  hardest.  There  are 
no  evidences  of  stasis  in  the  peripheral 
circulation,  but  the  lungs  are  evidently 
congested,  w^hile  both  in  the  superior 
and  in  the  inferior  vena  cava  stasis  is 
obvious.  The  cyanosis  and  engorge- 
ment of  the  cervical  veins  betray  back  pressure  in  the  domain  of  the 
superior  cava.  The  pain  under  the  right  costal  margin,  the  tenderness, 
and  the  enlargement  of  the  liver  give  evidence  that  the  inferior  cava 
cannot  empty  properly.  All  this  points  to  insufficiency  of  the  right 
ventricle. 

When  the  right  ventricle  is  insufficient,  the  cause  is  usually  to  be 
found  in  disease  of  the  mitral  valve,  much  less  often  in  chronic  emphy- 
sema or  other  long-standing  pulmonary  disease.  The  clinical  picture 
of  acute  tricuspid  regurgitation  due  to  dilatation  of  the  right  \entricle 
without  previous  mitral  disease  has  been  insisted  on,  especially  by 
Gibson  and  other  writers  in  Great  Britain,  but  as  yet  I  ha^•e  not  been 
able  to  verify  their  accounts  in  my  own  experience. 

What  form  of  mitral  disease  is  present  in  this  patient?  Besides 
mitral  regurgitation,  of  which  we  have  all  the  ordinary  classic  signs, 
we  have  a  very  sharp  first  sound,  such  as  rarely  accompanies  an  uncom- 
plicated mitral  regurgitation.     Even  without  the  occasional  occurrence 


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Fig.  189. — Chart  of  case  356. 


DYSPNEA  713 

of  a  short  presystolic  roll  we  should  be  right  in  assuming  the  presence 
of  mitral  stenosis  because  of  the  great  irregularity  of  the  heart  and  the 
sharpness  of  the  first  sound  at  the  apex.  The  doubling  of  the  second 
sound  in  the  pulmonary  area  still  further  justifies  this  assumption. 

Outcome. — The  patient  was  given  a  dry  diet  in  six  meals,  tincture 
of  digitalis,  10  minims,  every  six  hours,  |  grain  morphin  subcutaneously, 
repeated  later  in  the  night  and  on  two  subsequent  nights;  magnesium 
sulphate,  ij  ounces  every  morning.  Under  this  treatment  the  heart 
was  much  steadier  by  the  twenty-fourth,  though  still  irregular.  The 
area  of  dulness  was  smaller,  and  the  left  border  had  retreated  almost 
to  the  nipple-line.  By  the  twenty-seventh  he  was  able  to  sleep  well 
without  morphin.  The  presystolic  murmur  was  then  much  louder, 
the  heart  still  rapid  and  irregular.  By  the  third  of  January  the  cardiac 
apex  was  inside  the  nipple-line,  the  patient  was  able  to  mo^•e  about 
without  dyspnea,  all  the  edema  had  disappeared,  and  the  li\er  had 
retreated  behind  the  costal  margin.  By  the  seventh  he  \\as  able  to  go 
home. 

Since  the  heart  diminished  so  markedly  in  size  as  the  result  of  treat- 
ment, we  may  assume  that  we  are  dealing  at  the  start  with  a  case  of  acute 
cardiac  dilatation  supervening  upon  a  long-standing  disease  which  had 
narrowed  the  mitral  valve  and  prevented  it  from  closing  tightly. 

Diagnosis. — Mitral  stenosis  and  regurgitation. 


714 


DIFFERENTIAL   DIAGNOSIS 


TABLE   XX. — Dyspnea.     Signs  and  Symptoms. 


Causes. 


Suggestions 
friim  historv. 


Local  signs. 


Constitutional 
disturbances. 


Source  of  con-      y-,  ,  u   .  j- 

,,..,.  .      ■  M    J      I'Depend  on  what  disease 

Infectious  diseases tagion.     Mode  '^     ■ 

of  onset.  ^ 

Hypertrophy.     Arhyth- 

Cardiac  disease .Gradual  onset,  i  mia.     Murmurs.    Stasis 

in  lungs,  liver,  legs.       I 

'   t-      .,     ,  .  Circumscribed  apical 

Phthisis ^,^";'>'  '"f  °ry      bronchitis  or  solidifica- 

,  ot  tuberculosis. 

1  tion. 

I  I    Cardiac  hypertrophy. 

/.-I        .  u  •••  /-■      1      1  .       Hypertension.    Xnctu- 

Chronic  nephritis Gradual  onset.       •      "^  mu   „■        ti 

'^  ria.    Albumin.     Jbdema. 

Headache. 

Chronic    bronchitis   (usually  '  Winter  Bilateral  rales, 

with  bronchiectasis)    .    .    .      e.xacerbations  Nummular  sputa. 

I,  •  c    J  I  .         .'\.\illarv  pain.     Isobar 

I'neuinoma '    .Sudden  onset.  ,   ,     r         i-  re 

or  lobular  suhdincation. 

History  of  General  hyperreso- 

.Asthma previous  nance.      Piping  rales. 

paroxysms.  Kosinophilic  sputa. 

"  Barrel  chest."      Ex- 

Einphysema Gradual  onset,     tension  of  lung  borders. 

;  H\perresonance. 


Fever.  Often  leu- 
kocytosis. Pros- 
tration.    General 

aches.     Vomiting. 


Weakness. 
Insomnia. 


Fever.     F.macia- 

tion.      Dyspepsia. 

Weakness. 


Vomiting. 
Weakness. 


Fever.      Herpes. 

Lcukocvlosis. 

Vomiting. 

Weakness. 


Slight. 


Rest. 

Depletion. 

Stimulation. 


Hygiene. 
Climate. 


Rest. 

Depletion. 

Diet. 


Climate. 
Hygiene. 


Time. 


Morphin. 
Nitrites. 


Slight  or  absent. 


CHAPTER  XXII 

JAUNDICE 

There  is  no  authoritative  statement  or  logical  rule  which  settles 
the  minimum  amount  of  discoloration  which  shall  receive  the  name 
"jaundice,"  but  the  general  consensus  of  usage  applies  the  term  to  all 
cases  in  which  there  is  distinct  yellowing  of  the  conjunctiva,  whether 
the  skin  and  urine  show  any  demonstrable  change  or  not.  This  con- 
junctiva yellowing  must  be  distinguished  from  the  yellowish  patches 
of  subconjunctival  fat  to  be  seen  in  many  eyes. 

In  the  milder  cases  of  jaundice  we  can  see  around  the  iris  a  ring 
of  bluish-white  sclera  over  which  there  is  no  discoloration.  In  the 
more  intense  types  the  yellow  color  meets  the  iris. 

Like  all  judgments  depending  upon  a  color  test  alone,  the  decision 
whether  or  not  jaundice  is  present  is  by  no  means  an  infallible  one. 
Careful  inspection  of  the  deeper  portions  of  the  conjunctiva  in  many 
healthy  persons  shows  a  faint  shade  of  yellow  from  time  to  time,  and 
it  is  always  more  or  less  arbitrary  where  we  draw  the  line  between  this 
su])j:)Osedly  physiologic  condition  and  true  jaundice.  If  the  skin 
and  urine  are  not  discolored,  and  if  none  of  the  symptoms  of  gastro- 
duodenal  catarrh,  gall-stones,  or  cancer  are  ])resent,  it  is  customary  to 
overlook  and  disregard  many  a  faint  shade  of  yellow  upon  the  eye- 
ball, Init  I  am  not  sure  that  this  j^ractice  is  wise. 

TYPES  AND  CAUSES  OF    JAUNDICE 

The  distinction  Ijetween  a  hematogenous  and  a  hepatogenous 
jaundice  has  gone,  never  to  return.  Its  immortal  soul  survi\es  in  the  divi- 
sion between — (a)  Jaundice  which  owes  its  origin  in  the  first  in>tance 
to  an  infectious  disease,  such  as  |)ucrj)cral  sepsis  or  malaria,  and  ib) 
jaundice  due  to  mechanical  obstruction,  such  as  gall-stone  or  cancer. 
All  jaundice  is  he])atogenous  in  its  production,  but  the  original  cause 
may  be  infectious  or  mechanical. 

Doubtless  the  most  common  cause  of  jaundice  is  the  unknown  one, 
which  ])roduces  it  in  so  large  a  percentage  of  all  newborn  children, 
and  usually  occasions  no  diagnostic  difficulties.     In  clinical  work  we 

71"' 


7l6  DIFFERENTIAL  DIAGNOSIS 

are  apt  to  be  puzzled  especially  by  cases  of  jaundice  resulting  from  three 
causes : 

(a)  Gall-stones. 

(b)  Cancer. 

(c)  So-called  catarrhal  form. 

Less  common  and  less  puzzling  in  diagnosis  are  the  cases  due  to : 

(d)  Cirrhosis. 

(e)  Syphilis  of  the  liver. 

All  these  are  of  the  obstructive  type,  and  are  therefore  distinguished 
from  the  infectious  varieties  mentioned  above.  Rare  and  obscure 
causes  for  jaundice  are  exemplified  in : 

(J)  Acute  liver  atrophy,  with  or  without  poisoning  by  chloroform  or 
phosphorus. 

(g)  Weil's  and  the  other  types  of  infectious  jaundice  of  unknown 
origin. 

(h)  Family  hemolytic  jaundice. 

The  so-called  catarrhal  jaundice  is  probably  the  commonest  of  all 
the  forms  just  mentioned.  It  is  also  the  least  understood.  The  old 
idea  of  a  catarrh  spreading  up  into  the  common  bile-duct  from  the 
duodenum  has  very  little  support  either  in  postmortem  demonstration 
or  in  the  clinical  course  of  the  disease.  Many  of  the  cases  bear  all  the 
external  evidences  of  a  mild  general  infection  and  are  indistinguishable, 
when  they  occur  sporadically,  from  Weil's  disease,  which  is  a  name  given 
to  epidemics  of  jaundice  associated  with  a  fever  lasting  from  four  to 
nine  days,  a  sudden  onset  with  muscular  pains  and  sometimes  with  a 
palpable  spleen. 

Both  catarrhal  jaundice  and  Weil's  disease  are  distinguished  from 
acute  yellow  atrophy  of  the  liver  only  by  their  course,  and,  for  aught 
we  know,  may  be,  in  fact,  mild  forms  of  the  same  infection.  The  liver 
is  notoriously  strong  in  its  power  of  regeneration  after  injury,  and  it 
may  well  be  that  the  cases  which  we  now  term  acute  yellow  atrophy 
represent  merely  its  occasional  failures,  while  catarrhal  jaundice  and 
Weil's  disease  exemplify  its  much  more  frequent  victories  over  some  of 
the  poisons  that  lead  to  necrosis. 

ASSOCIATED  SYMPTOMS 

A  slow  pulse,  a  tendency  to  mental  depression  and  to  uncontrollable 
oozing  from  any  wounded  surface,  are  usually  associated  with  the 
severer  types  of  jaundice.  ]\Iore  troublesome  and  more  interesting  is 
the  itching,  which  is  frequently  but  by  no  means  always  a  concomitant 
of  jaundice.     A  patient  of  mine  suffered  two  attacks  of  severe  jaundice 


Causes  of  Jaundice 


1.  ICTERUS  NEONATORUM    ] 

!     CASES  TOO   NUMEROUS  AND  TOO  VAGUELY    ENUMERABLE 


FOR   GRAPHIC    REPRESENTATION. 


2.  SEPSIS 


GALL-STONES  ^^I^HBBHHH^^H^^^^i^^^HHiH  369 


4.  "CATARRHAL 
JAUNDICE 


7.  CANCER      OF 

Bl  LE-DUCTS 
AND  G  A  L  L- 
BLADDER 

8.  CANCER    OF) 

PANCREAS) 


10.  CANCER  OF 
DUO 


EROF     I 
DENUMi  ' 


131 


5.  CANCER  OF  LIVER    i^^HB  57 

6.  CIRRHOSIS  BI^^H  48 


26 


17 


9.  GASTRIC  CAR- •> 

CINOMA  i  "  '^ 


717 


JAUNDICE  719 

within  six  months.  Both  were  due  to  gall-stones  and  ran  approximately 
the  same  course,  but  in  one  he  was  tormented  with  itching,  in  the  other 
he  was  wholly  free  from  it.  About  half  the  cases  itch  and  half  do  not. 
This  proves  to  my  satisfaction  that  the  itching  is  not  due  merely  to  the 
presence  of  bile  in  the  skin  and  subcutaneous  tissues.  Some  other  and 
less  constant  factor  must  be  present  when  itching  occurs. 

INTENSITY  OF   JAUNDICE 

As  a  rule,  the  deepest  discoloration  occurs  in  complete  and  permanent 
occlusion  of  the  bile-ducts  by  cancer.  In  gall-stones  the  depth  of  the 
yellow  staining  is  apt  to  \ary  from  week  to  week.  In  the  so-called 
catarrhal  forms  the  color  is  usually  paler,  but  there  are  striking  excep- 
tions to  this  rule.  The  jaundice  of  infectious  disease,  of  hepatic  cir- 
rhosis, and  syphilis  is  generally  moderate  in  degree. 

Case  371 

A  laboratory  worker,  forty-seven  years  of  age,  entered  the  ward 
July  30,  1906,  with  the  following  history.  Two  weeks  ago,  while  on 
his  vacation,  he  felt  some  discomfort  after  eating  and  lost  his  ap])etite. 
A  day  or  two  later  his  skin  turned  yellow,  his  urine  dark.  Five  days 
after  this  his  stools  became  clay-colored.  He  has  vomited  only  twice, 
yesterday  and  the  day  before.  He  has  no  j)ain.  His  bowels  mo\"e 
daily.  He  feels  very  mean  and  seedy  and  is  troubled  with  itching. 
Two  weeks  ago  he  weighed  161  ])ounds,  now  he  weighs  142.  He  has 
never  had  an  attack  similar  to  this. 

On  examination,  the  edge  of  the  liver  is  easily  felt  below  the  costal 
margin.  The  jaundice  is  fairly  well  marked.  In  other  respects  the 
physical  examination,  including  Ijlood  and  urine,  is  negati\e.  The 
y)atient  seemed  unaccountably  weak  and  continued  so  e\'cn  up  to  the 
twelfth  of  August.     At  that  time  his  color  began  to  fade. 

Discussion. — A  jaundice  of  four  weeks'  duration,  associated  with 
enlargement  of  the  li\"er,  loss  of  weight,  and  marked  ])rostration  in  a 
man  forty-seven  years  old. 

He  has  had  no  pain,  no  chill,  fc\"cr,  or  ])alpal)k'  gall-l)hukier  in  this 
attack.  He  has  had  no  previous  seizures.  So  far  as  liiis  e\i(lencc  goes, 
it  is  against  the  diagnosis  of  stone,  thougli  it  is  ])erfectly  ])ossil)lo  that 
slonc  may  exist. 

Malignant  disease  was  mucli  feared  by  the  patient,  who  could  not 
understand  why  he  was  so  weak  and  thin  unless  there  was  some  ^■ery 
>erious  disease  underlying  his  --vniptonis.      F)Ut  of  maliL^nant  disea-t'. 


720  DIFFERENTIAL    DIAGNOSIS 

as  of  stone,  we  have  no  positive  evidence.  After  four  weeks  of  complete 
jaundice  one  exj^ects  to  find  ascites,  enlarged  gall-bladder,  or  nodular 
liver  if  the  jaundice  be  due  to  malignant  disease.  The  absence  of  any 
history  of  pre\ious  stomach  trouble  is  also  a  comforting  consideration, 
since  malignant  disease  involving  the  li\er  is  usually  preceded  by  cancer 
of  the  stomach.  In  particular,  howe^'er,  it  should  be  said  that  emacia- 
tion during  an  attack  of  jaundice  is  no  evidence  whatever  regarding  its 
cause  and  is  just  as  likely  to  occur  in  a  gall-stone  attack  as  in  malignant 
disease. 

Of  the  other  common  causes  of  jaundice,  such  as  cirrhosis,  syphilis, 
or  acute  infectious  disease  (toxemic  jaundice),  we  have  no  evidence. 

Under  these  conditions,  when  we  have  exhausted  our  efforts  in  the 
attempt  to  find  evidence  of  stone,  cancer,  and  the  other  less  common 
causes  of  jaundice,  we  fall  back  upon  the  old  term  "catarrhal  jaundice," 
one  of  the  most  insecurely  founded  of  all  the  diagnoses  that  are  in  good 
standing  at  the  present  time.  If  the  facts  were  known,  it  would  probably 
turn  out  that  a  considerable  number  of  the  cases  called  "catarrhal 
jaundice"  are  really  due  to  stone  and  that  the  remainder  are,  like 
pur])ura,  the  expression  of  various  unnamed  infectious  processes. 
Jaundice  is  almost  as  general  and  indistincti\'e  a  manifestation  as 
fever. 

Outcome. — By  the  sixteenth  of  August  the  patient's  appetite  had 
returned,  and  after  a  short  vacation  in  the  country  he  came  back  to  work 
apparendy  in  perfect  health.  Up  to  the  present  time  (May,  1910)  he 
has  remained  entirely  well. 

Epicrisis. — This  case  is  fairly  illustrative  of  two  points: 

(a)  The  vague  opportunism  of  our  diagnoses  of  catarrhal  jaundice, 
which  must  be  changed  at  any  moment  if  more  distincti\'e  symptoms 
pointing  to  gross  organic  disease  make  their  appearance.  At  best  such 
a  diagnosis  is  justified  only  by  the  outcome  of  the  case,  and  at  any  time 
we  may  ha\'e  to  eat  our  words  if  colic,  ascites,  or  a  palpable  mass  appears. 

(b)  The  frequency  of  emaciation  in  jaundice  of  any  type.  I  have 
known  a  physician  to  be  seriously  alarmed  about  his  own  condition 
during  the  course  of  an  attack  of  jaundice,  obviously  due  to  gall-stone, 
because,  as  he  said,  "How  can  a  little  stone  stuck  in  a  duct  make  me 
lose  40  pounds  in  two  months?"'  Nothing  but  the  removal  of  the  stone 
and  his  rapid  return  to  his  former  weight  and  health  convinced  him. 
Whether  the  emaciation  in  cases  of  this  kind  is  wholly  the  result  of 
anorexia  and  insufficient  food,  or  whether  there  is  some  more  obscure 
reason  connected  with  the  functions  of  the  liver,  I  do  not  know. 

Diagnosis. — Catarrhal  jaundice. 


JAUNDICE 


721 


Case  372 

A  stableman  of  forty- two  entered  the  hospital  June  16,  1908.  Within 
three  years  the  patient  has  had  three  attacks  of  rather  persistent  indiges- 
tion, characterized  by  sharp,  colicky  pain  localized  about  the  umbilicus 
and  sometimes  needing  morphin.  He  says  he  has  never  been  jaundiced. 
Two  years  ago  he  weighed  180  pounds;  two  months  ago,  170,  now  he 
weighs  134.  He  averages  two  glasses  of  beer  a  day  and  twenty  cents' 
worth  of  tobacco  a  week. 

For  the  past  two  weeks  he 
has  been  in  bed  most  of  the 
time,  complaining  of  drowsi- 
ness, anorexia,  slight  fever,  and 
aches  all  over  his  body,  es- 
pecially in  the  lumbar  region. 
He  saw  a  physician  for  the  first 
time  four  days  ago,  who  told 
him  that  he  was  jaundiced.  At 
that  time  his  skin  began  to  itch 
and  his  stools  to  be  a  light  clay 
color.  The  urine  has  been  dark 
for  a  week.  The  course  of  the 
tcm])erature  is  seen  in  the  ac- 
comjmnying  chart. 

Examination  showed  moder- 
ate jaundice  and  nothing  else  ex- 
cept that  the  white  cells  were 
17,000  at  entrance,  declining  three  days  later  to  12,000.  The  urine 
was  always  normal,  except  for  the  presence  of  bile.  Blood-])ressure 
was  145  mm.  Hg. 

Discussion. — In  the  discussion  of  a  previous  case  I  referred  to 
the  humiliating  fact  that  in  many  cases  of  jaundice  we  have  to  wait 
for  time  to  show  whether  our  conjectures  arc  right  or  not.  Experience 
has  shown  that  most  cases  of  so-called  "catarrhal''  jaundice  clear  up 
within  six  weeks,  and  that  most  of  those  which  run  over  this  limit  turn 
out  to  l)c  due  to  gall-stones  or  malignant  disease.  The  period  referred 
to  is,  of  course,  a  ])erfectly  arbitrary  one,  based  upon  averages,  and 
with  very  little  anatomic  evidence  to  sup])ort  it.  The  j)resent  case  ran 
its  course  within  this  traditional  limit  without  the  devel()])ment  of  any 
])ain,  ascites,  nodular  mass,  or  toxemic  state. 

Nevertheless,  we  can  1)y  no  means  be  sure  that  the  attack  was  not 

4(1 


■SS,?  D/^  '■i,f\,9u>U'-^-u^J^ 

J^i.}  it  ^Jt       /     JL       i      •.      t     i 

=— 1      -/I/I/      f      /     -  +  - 

---'■/-    mi  III  //-//-- 

,„.  ■•••••*tH(j«.<ii>»<P< 

•  m<rY'!«<»<>*«¥<^1«i 

. 

. 

. 

^-f.AA_i^ 

jK    LM.  .    ^ 

-  .-^^22Evre2^ 

ttzt^i.t^f.^:^ 

IM     -^ 

1«    ^t 

"•     -? 

a 

"? 

a 

IM     ^ 

"     "                                                     S 

^a>.       -»       81      — 

s,33?t*'iC* 

"     ^               ^             »»^ 

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«  ^^A:Z^*Z^^ 

^  .'-l^-S'W^/^!    >w^ 

Z     iKh^l  'A 

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a 

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- 

I   ^ 

a 

« 

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U,L         Ji           .''^«.    „ 

V^;^«=^^     -c-V- 

u   li           Li'^      3     ^Jffil 

ri            74         1^ 

Fig.   190. — Chart  of  case  372. 


722  DIFFERENTIAL   DIAGNOSIS 

due  to  gall-stones,  especially  as  he  has  had  three  previous  seizures 
which  remind  us  very  distinctly  of  that  disease.  If,  at  any  time  within 
the  next  few  years,  the  patient  has  a  typical  gall-stone  attack,  it  will 
seem  more  than  likely  that  the  present  attack,  as  we  view  it  in  retro- 
spect, was  also  due  to  gall-stones. 

Although  the  relation  of  alcohol  to  cirrhotic  liver  (a  possible  cause 
of  jaundice)  is  not  clear,  wc  certainly  know  enough  to  say  that  this 
patient  has  not  taken  enough  beer  to  put  him  in  peril  of  chronic  inter- 
stitial hepatitis.  Of  the  nature  and  development  of  that  disease  we 
know  so  little  from  a  clinical  standpoint  that  we  are  unal^le  to  make 
positive  statements  about  its  earlier  stages  and  their  relation  to  symptoms 
like  those  here  described.  Certainly,  however,  no  one  would  be  justified 
in  giving  more  than  passing  consideration  to  cirrhosis  in  the  present  case. 

Outcome. — On  the  twenty-seventh  the  jaundice  was  much  less 
marked  and  the  patient  was  hungry.  On  the  eighteenth  of  July  the 
jaundice  had  completely  disappeared,  the  patient  had  gained  six 
pounds  since  entrance,  and  felt  entirely  well. 

On  the  first  of  September  he  reported  that  he  had  been  perfectly 
well  and  had  worked  ever  since  leaving  the  hospital.  His  weight  was 
151  pounds.     There  was  no  evidence  of  jaundice. 

Diagnosis. — Catarrhal  jaundice. 

Case  373 

A  schoolboy  of  thirteen,  always  previously  well,  consulted  a  physician 
with  the  statement  that  for  two  months  he  had  been  jaundiced  and  had 
intermittent  dull  ])ains  across  the  upper  abdomen.  At  the  onset  of  his 
illness  he  had  a  chill  and  considerable  vomiting  for  three  days,  but  these 
symptoms  have  not  recurred.     He  was  first  seen  September  4,  1907. 

Examination  showed  deep  jaundice.  The  spleen  and  li\er  easily 
felt.  (See  accompanying  diagram.  Fig.  191.)  The  edge  of  the  spleen 
was  hard,  the  whole  organ  freely  mo^■al)Ie.  The  white  cells  numbered 
3800;  hemoglobin,  100  per  cent.;  stained  specimen  normal,  as  was  the 
urine.  The  feces  were  not  bleached.  Later  it  was  ascertained  that 
a  year  ago  he  had  had  chills  and  fever  e\'ery  other  day  for  a  considerable 
period. 

The  boy  was  given  lif}uid  and  soft  solid  diet,  sodium  phosphate,  -i 
dram  every  morning,  and  under  this  treatment  rapidly  improved.  He 
was  able  to  take  full  diet  l)y  the  seventh,  was  much  less  jaundiced  by 
the  ninth,  and  by  the  fourtccntli  had  no  visible  discoloration  of  the  skin  or 
conjunctivae.  Tn  view  of  the  history  it  seemed  best  to  give  him  i^  grains 
of  quinin  three  times  a  day  for  ten  days. 


Fig.  igt. — Shows  results  of  |)hysical   cxamiiniioa  in  a  ca.-c-  uf  jaundice  of  two  months' 

duration. 


JAUNDICE  723 

Discussion. — ^This  patient  had  absolutely  no  complaints  at  the 
time  when  this  history  was  written.  His  parents  wanted  to  know 
why  his  eyes  were  yellow,  but  he  himself  did  not  feel  sick  at  all. 

The  presence  of  an  enlarged  hard  spleen  and  the  history  of  a  chill 
at  the  onset  remind  us  that  malaria  is  a  not  infrequent  cause  of  jaundice. 
Yet  certainly  at  the  present  time  he  has  no  active  malarial  infection.  Is 
it  possible  that  the  icterus  may  be  a  relic  of  a  past  malaria?  Certainly 
in  the  more  severe  types  of  the  disease  jaundice  often  persists  when  no 
parasites  are  discoverable  in  the  peripheral  circulation  and  when  the 
temperature  is  steadily  normal.  In  the  milder  tertian  infections  of 
New  England  one  does  not  often  see  this,  especially  when  the  attack 
has  not  destroyed  enough  corpuscles  to  lower  the  hemoglobin,  which 
was  100  j)cr  cent,  in  this  case.  On  the  whole,  therefore,  this  hypothesis 
seems  unlikely. 

Gall-stones  are  rarely  found  in  boys  of  this  age.  The  pains  which 
previously  troubled  him  were  ne\er  such  as  to  suggest  biliary  colic, 
and  the  fact  that  the  stools  were  never  decolorized  makes  it  seem  improba- 
ble that  the  stone  has  never  blocked  the  ducts. 

Catarrhal  jaundice  may  occur  at  this  age,  though  it  is  not  common. 
If  we  use  the  term  to  include  any  brief  icterus  of  unknown  origin  and 
sporadic  occurrence,  it  \vill  doubtless  cover  such  cases  as  this,  e^■en 
though  no  digesti\-e  symptoms,  such  as  should  accompany  a  gastro- 
duodenal  catarrh,  were  complained  of.  In  all  probability  the  jaundice 
rej)resent.s  one  manifestation  of  an  acute  infectious  disease.  Had  it 
occurred  in  an  epidemic  form,  it  might  have  passed  as  Weil's  disease. 

Outcome. — On  October  i6th  the  boy  returned  to  the  physician  to 
rc])ort  that  two  days  previously  he  had  had  a  chill  and  fever.  The 
boy  had  gained  considerably  in  flesh,  and  looked  entirely  well.  The 
S[)leen  was  still  palpable,  the  liver  no  longer  so.  Malarial  parasites 
were  now  demonstrated  in  the  blood.  In  ^iew  of  this  fact  it  seems, 
on  the  whole,  probable  that  his  jaundice  was  due  after  all  to  malaria. 

Diagnosis. — Tertian  malaria. 

Case  374 

A  housewife  of  thirty-eight,  of  good  family  history  and  past  liistory, 
entered  the  hos])ital  September  3,  igoy.  She  began  six  months  ago 
to  have  what  she  calls  "a  ball ''  in  the  stomach,  starting  at  thccpiga-trium 
and  m()\ing  toward  the  left  hypochondriuni.  A|)partntly  >hc  lias 
steady,  dull  epigastric  ])ain,  not  radiating,  accompanied  by  licart-l)urn. 
anf)rcxia,  a  bad  taste  in  the  mouth,  distress  and  flatulence  after  eating, 
constipation,  and  occasional  \oniiting  of  the  food  la>t  taken.     Through- 


724  DIFFERENTIAL   DIAGNOSIS 

out  this  six  months  she  has  had  jaundice,  varying  in  intensity.  She 
has  had  also  occasional  chills,  followed  by  profuse  sweating,  and  always 
by  an  increase  in  the  jaundice  and  in  the  color  of  the  urine.  At  no 
time  has  she  had  any  sudden  or  sharp  pain  anywhere.  She  has  lost 
30  pounds  in  the  last  six  months.  She  sleeps  poorly  on  account  of 
flatulence. 

Examination  shows  an  obese,  jaundiced  woman,  with  an  indefinite 
resistance  under  the  costal  margin  and  in  the  median  line.  Physical 
examination,  including  the  temperature,  pulse,  respiration,  blood, 
and  urine,  is  otherwise  negative,  save  for  the  presence  of  bile  in  the 
urine. 

Discussion. — If  this  jaundice  had  not  already  lasted  for  six  months, 
it  would  very  probably  deserve  to  be  called  "catarrhal,"  as  no  doubt 
it  was  called  in  the  earlier  weeks  of  its  occurrence.  No  one  maintains, 
however,  that  the  term  "catarrhal"  should  be  extended  to  cover  cases 
of  six  months'  duration. 

The  variations  in  the  intensity  of  the  jaundice  and  the  occurrence 
of  chills  without  malarial  parasites  in  the  blood  lead  us  to  favor  the 
diagnosis  of  gall-stones.  But  can  one  have  gall-stones  without  any  colic ; 
indeed,  without  any  pain  except  such  as  might  be  attributed  to  flatulence? 
Thanks  to  the  surgeon  we  may  now  answer  this  question  with  an  un- 
qualified affirmative.  Colic  is  a  common  but  by  no  means  an  in^•ariable 
accompaniment  of  cholelithiasis. 

The  loss  of  weight  which  occurs  in  all  forms  of  jaundice  has  been 
discussed  in  the  previous  cases  and  shown  to  have  in  itself  no  diagnostic 
significance.  The  age,  the  sex,  and  the  obesity  all  favor  the  diagnosis 
of  gall-stones. 

Outcome.— Operation  September  6th  revealed  a  stone  in  the  lower 
end  of  the  common  duct.  The  bile-passages  were  otherwise  free,  the 
liver  and  pancreas  not  abnormal.  The  patient's  convalescence  was 
une\entful,  and  after  October  6th  she  seemed  and  remained  entirely 
well. 

Diagnosis. — Gall-stones. 

Case  375 

An  Irish  housekeeper  of  thirty-eight,  whose  husband  now  is  con- 
sumptive, entered  the  hospital  August  29,  1907.  She  has  always  been 
well,  and  has  a  good  family  history.  For  nine  years  she  has  had  fre- 
quent sick  headaches,  accompanied  by  vomiting.  For  two  years  she 
has  had  gradual  loss  of  weight  and  strength,  her  weight  declining  from 
159  pounds  two  years  ago,  to  119.  at  the  present  time. 


Fig.  192. — Shows  conclusions  drawn  from  examination  of  a  case  of  intermittent  painless 
jaundice  lastini^  three  mo!iths. 


JAUNDICE  725 

For  three  months  she  has  had  jaundice,  varying  in  intensity.  She 
has  had  no  pain  at  any  time.  Two  hours  after  eating  she  not  infre- 
quently vomits,  the  vomitus  consisting  only  of  food.  Her  appetite  is 
good.  The  bowels  move  with  the  aid  of  sodium  phosphate.  She  sleeps 
well.     Her  present  complaint  is  of  weakness  and  jaundice. 

Physical  examination  shows  the  jaundice  to  be  heavy.  The  chest  is 
negative.  The  condition  of  the  abdomen  is  shown  in  the  accompanying 
diagram,  Fig.  192.  Blood  and  urine  are  normal.  The  coagulation 
time  of  the  blood  is  one  minute  five  seconds  with  the  Brodie-Russell 
instrument. 

Discussion. — A  gradual  decline  in  weight  and  strength  during 
a  period  of  two  years,  leading  up  to  a  jaundice  of  three  months'  duration 
and  of  variable  degree,  and  accompanied  by  occasional  attacks  of 
vomiting,  is  rather  an  unusual  clinical  picture  in  a  woman  of  thirty- 
eight.  Why  should  the  loss  of  weight  have  preceded  the  jaundice  unless 
some  form  of  malignant  disease  is  present?  Yet  if  any  such  disease 
were  ])rcsent  it  should,  ]\v  this  time,  show  more  olnious  evidence  of 
itself.  Without  ascites,  marked  gastric  symptoms,  or  palpable  tumor 
we  certainly  cannot  make  a  diagnosis  of  such  terrible  significance  to  the 
patient.  Yet  from  our  own  minds  it  is  difficult  to  exclude  the  thought 
of  cancer. 

Cirrhosis  or  syphilis  of  the  liver  would  probably  show  more  definite 
signs  of  their  presence  after  an  illness  of  this  length. 

Under  such  conditions,  when  a  jaundice  has  lasted  rather  too  long 
to  be  called  "catarrhal,"  yet  has  not  produced  any  of  the  more  ominous 
evidences  of  cancer,  cirrhosis,  or  sy])hilis,  the  outcome  usually  shows 
that  we  arc  dealing  with  gull-stones.  We  have  to  be  governed  largely 
by  statistical  evidence  in  such  cases;  direct  examination  yields  \ery 
little  of  value.  Indeed,  there  is  no  class  of  diseases  in  which  we  depend 
so  largely  upon  the  history  and  upon  general  statistical  ex])erience  as 
we  do  in  diseases  of  the  liver.  Physical  examination  ])lays  here  a  smaller 
])art  than  in  the  diseases  of  any  other  organ  with  which  we  deal  on  terms 
of  any  confidence. 

Outcome. — At  operation.  Septeml)er  6th,  scNcral  larze  stones  were 
found  in  the  gall-bladder  and  one  in  the  cystic  duct.  No  obxious 
reason  for  the  jaundice  was  found;  there  was  no  swelling  extending 
down  from  the  blocked  cystic  duct  to  the  hepatic  or  to  the  chok'dochus  — 
an  explanation  which  is  often  inxoked  to  ex])lain  jaundice  when  the 
stone  is  in  the  cystic  duct.     No  other  reason  could  be  found. 

Recovery  was  complete  and  ])ermanent. 

Diagnosis. — Oall  >tones. 


726  DIFFERENTIAL  DIAGNOSIS 

Case  376 

An  Italian  widow  of  sixty,  of  negative  family  history  and  past  history, 
was  first  seen  March  9,  1908.  She  had  noticed  a  year  ago  that  she 
was  jaundiced  and  had  a  swelling  in  the  region  of  her  liver.  After  two 
weeks  she  was  cured  of  her  jaundice,  but  the  swelling  continued  and 
increased.  Seven  months  ago  the  jaundice  returned  and  has  been  present 
most  of  the  time  since.  She  has  not  lost  much  weight,  though  her 
appetite  is  poor.  She  has  much  nausea,  no  pain,  and  no  vomiting. 
For  two  weeks  she  has  had  edema  of  the  feet. 

Physical  examination  showed  a  deeply  jaundiced  patient.  Both 
pupils  were  irregular,  the  left  larger  than  the  right.  Both  reacted 
normally.  The  heart's  action  was  at  times  irregular  in  force  and 
rhythm,  and  a  blowing  systolic  murmur  was  audible  all  over  the  precordia. 
The  pulmonic  second  sound  was  louder  than  the  aortic  second,  the 
apex  beat  in  the  fifth  space  just  outside  the  nipple-line.  The  pulse 
was  of  low  tension.  The  lungs  showed  nothing  abnormal.  The 
abdomen  was  enormously  distended,  dull  in  the  epigastrium  and  in  the 
flanks,  otherwise  tympanitic.  The  circumference  was  40  inches.  The 
umbilicus  protruded.  The  edge  of  the  liver  was  easily  felt  5  inches 
below  the  costal  margin.  Its  surface  was  smooth,  hard,  not  tender, 
somewhat  irregular.  The  spleen  ^^•as  not  felt.  There  was  considerable 
soft  edema  of  the  legs  and  of  the  anterior  abdominal  wall.  The  shape 
of  the  abdomen  suggested  encysted  rather  than  free  fluid.  Blood  and 
urine  were  normal. 

On  the  eleventh  233  ounces  of  fluid  were  withdrawn  by  tapping  the 
abdomen.  It  was  bile-stained,  1009  in  specific  gra\'ity.  The  sediment 
showed  60  per  cent,  of  lymphocytes  to  40  per  cent,  endothelial  cells. 
After  tapj)ing,  the  surface  of  the  liver  \^•as  a})parently  smooth,  and 
extending  down  from  its  edge  in  the  region  of  the  gall-bladder  was  a 
dense,  fluctuant,  rounded  mass  the  size  of  an  apple,  not  tender.  (See 
Fig.  193.)  After  tapping,  the  fluid  rapidly  reaccumulated.  The 
])atient  seemed  entirely  comfortable,  complaining  of  nothing  at  all. 
She  was  again  tapped  on  the  third  of  ATjril  and  164  ounces  removed, 
the  characteristics  of  the  fluid  being  essentially  the  same  as  before. 
About  this  time  she  ran  a  moderate,  irregular  fexer,  reaching  as  high 
as  101°  F.  at  niglit,  and  1)eing  normal  in  the  morning.  This  subsided 
after  about  ten  days. 

Discussion. — With  jaundice  of  seven  months'  duration,  a  li^•er 
markedly  enlarged,  ascites,  and  swelled  legs,  we  should  have  no  con- 
sideral)le  doubt  that  malignant  disease  is  present  were  it  not  for  the 


Fig.  193. — Results  of  physical  examination  in  Case  376.     Jaundice  has  lasted  one  year. 
No  j)ain  or  emaciation. 


JAUNDICE  727 

fact  that  the  patient  has  also  an  enlarged  and  irregular  heart,  whose 
action  is  presumably  insufficient  to  maintain  satisfactory  circulation. 
The  ascites  and  edema  may  be  due  to  cardiac  weakness  rather  than  to 
malignant  disease. 

On  the  other  hand,  the  irregularity  of  the  liver  surface,  if  it  be  a 
fact,  is  of  decisive  importance  in  this  connection;  for  such  irregularity, 
if  gross  enough  to  be  palpal jle  through  the  abdominal  wall,  means  one  of 
two  things  in  practically  all  cases,  viz.,  hepatic  cancer  or  hepatic  syphilis. 
If  the  first  physical  examination  be  correct,  then,  the  cardiac  condition 
is  probably  not  responsible  for  the  dropsy. 

As  between  cancer  and  syphilis,  we  should  be  influenced,  in  the  first 
place,  by  statistical  considerations;  cancer  is  by  far  the  commoner  of 
the  two  as  the  cause  of  jaundice  and  ascites.  The  absence  of  splenic 
enlargement  is  also  against  syphilis.  Less  important  is  the  absence 
of  any  history  of  syphilis  and  of  any  evidence  of  its  ravages  in  other 
parts  of  the  body. 

If  we  are  dealing  with  cancer,  what  is  its  site?  Probably  not  the 
substance  of  the  liver,  since  hepatic  cancer  is  usually  secondary  to  similar 
disease  at  the  pylorus.  This  patient  has  been  free  from  gastric  symp- 
toms. If  not  in  the  liver  itself,  the  cancerous  obstruction  which  has 
produced  the  jaundice  is  probably  at  one  of  three  points : 

(a)  At  the  duodenal  papilla. 

(b)  In  the  head  of  the  pancreas,  compressing  the  common  duct. 

(c)  In  the  gall-bladder  or  bile-ducts  themselves.  Beyond  this  we 
cannot  go. 

Outcome. — April  12th,  after  more  than  a  month  in  a  hospital,  she 
showed  aljsolutcly  no  loss  of  weight  and  we  were  rather  shaken  in  our 
confidence  that  cancer  was  the  correct  diagnosis.  Xcvcrtheless,  o])era- 
tion  was  performed  April  14th,  as  the  ])alicnt  showed  no  signs  of  im])rove- 
ment  after  a  thorough  course  of  antisyphilitic  treatment.  A  cancer  of 
the  head  of  the  pancreas  was  found. 

Diagnosis. — Pancreatic  cancer. 

Case  377 

An  American  timekeeper  of  twenty  began,  in  1Q03,  to  have  epi- 
gastric pain,  after  eating,  in  intermittent  spells  lasting  a  month  or  two. 
In  Januarv,  1907,  this  ])ain  became  2iiuch  worse,  and  lie  vomited  fresh 
l)lood.  In  March,  1907,  he  entered  the  hos])ital  and  was  found  to 
liave  a  marked  hyperchlorhydria,  which,  taken  in  connection  with  the 
above  s\'m])toms,  led  to  an  o])eration,  whicli  showed  adhesions  about 
the  pylorus  and  considerable  thickening  of  the  ])ylorus,  witliout  cNidcnce 


728  DIFFERENTIAL   DIAGNOSIS 

of  cancer.  A  posterior  gastro-enterostomy  was  accordingly  done.  The 
patient  did  excellently  well,  and  went  home  ^ree  from  symptoms  on  the 
seventh  of  April,  1907. 

He  returned  a  year  later  (April  24,  1908)  with  the  following  history: 
A  month  ago  became  suddenly  jaundiced  immediately  after  taking 
some  sulphur  and  molasses.  He  has  remained  so  ever  since,  though 
his  color  has  l^ccn  becoming  lighter.  At  the  same  time  he  has  com- 
plained of  rather  dull  pain,  felt  from  time  to  time  in  the  lower  abdomen. 
For  a  week  this  has  been  absent.  For  two  weeks  he  has  not  worked, 
and  has  been  on  a  milk  diet.  During  this  time  he  has  had  a  slif^ht 
cough ,  with  yellowish  or  greenish  sputum.  He  has  a  great  deal  of  itching, 
and  has  noticed  that  his  urine  is  dark.  Yesterday  at  half-past  four  he 
ate  a  very  hearty  dinner.  Later  in  the  day  he  vomited  and  gradually 
became  unconscious,  possibly  from  the  effects  of  morphin  which  was 
given  in  the  evening.     There  is  no  headache,  no  fever,  no  loss  of  weight. 

Examination  shows  normal  temperature,  pulse,  and  respiration. 
There  is  marked  jaundice.  The  patient  is  semicomatose,  with  dilated 
pupils  which  do  not  react.  The  chest  is  negative.  The  abdomen  is 
level,  rather  rigid,  tympanitic;  nothing  else  is  made  out.  The  liver 
flatness  reaches  from  the  fifth  rib  to  the  seventh  space,  measuring  2^ 
inches  in  vertical  diameter  in  the  nipple-line.  The  urine  is  high  in 
color,  specific  gravity  1020,  with  a  very  slight  trace  of  allmmin  in  the 
sediment,  no  casts,  a  large  amount  of  leucin  and  tyrosin.  The  white 
cells  are  9200;  hemoglobin,  75  per  cent. 

Discussion. — We  will  take  first  the  second  chapter  of  this  patient's 
case,  after  his  recovery  from  the  gastro-enterostomy. 

In  the  earlier  weeks  of  his  jaundice  the  brittle  and  unsatisfactory 
term  "catarrhal"  was  as  usual  a]j])lied,  and  one  could  hardly  have 
done  otherwise  until  the  appearance  of  one  very  distinctive  and  ominous 
symptom,  stupor.  None  of  the  milder  and  more  curable  causes  of 
jaundice  })roduce  this  sym])tom.  We  never  meet  it  in  the  catarrhal 
forms,  in  gall-stones,  or  in  malignant  disease  [previous  to  the  terminal 
stages.  In  the  infectious  forms  of  jaundice,  stupor  appears  only  near  a 
fatal  issue. 

Only  in  two  forms  of  liver  disease  which  are  accom])anied  by  jaundice 
does  stupor  ai)])ear — in  cirrhosis  and  in  acute  yellow  atro])hy.  Either 
of  these  diseases  might  be  present  here,  although  we  have  no  history  of 
alcoholism  such  as  usually  appears  to  enter  into  the  causation  of  cirrhosis, 
at  any  rate,  as  one  factor.  Another  jjoint  against  cirrhosis  and  in  favor 
of  acute  yellow  atrophy,  is  the  ra])idity  of  the  shrinkage  a})parently 
demonstrable  by  percussion  of  the  liver  outlines.     Shrinkage  of  the 


JAUNDICE 


729 


liver  can  very  seldom  be  demonstrated  during  life.  When  the  area  of 
liver  dulness  appears  to  be  less  than  normal  it  usually  turns  out  to  be 
obscured  by  a  distention  of  the  colon  which  pushes  the  liver  backward 
out  of  reach  of  the  percussing  linger. 

In  the  present  case,  however,  the  area  of  dulness  was  again  and  again 
measured,  and  showed  apparently  a  progressive  shrinkage.  This  fact, 
taken  in  connection  with  the  deep  jaundice,  the  increasing  coma  and  the 
presence  of  leucin  and  tyrosin  in  the  urine,  made  us  tolerably  confident 
that  a  rapid  atrophy  of  the  liver  was  in  progress.  No  hint  of  its  etiology 
was  oljtaincd;  the  patient  had  not  inhaled  chloroform  or  ingested 
phosphorus  in  any  form. 

Outcome. — On  the  morning  of  the  twenty-sixth  the  liver  dulness 
was  only  if  inches  in  vertical  diameter;  the  jaundice  had  considerably 
decreased.  The  patient  continued  semicomatose.  On  the  afternoon 
of  the  twenty-sixth  he  developed  edema  of  the  lungs  and  died. 

Autopsy  showed  acute  yellow  atrophy  of  the  li\'er,  obsolete  tuber- 
culosis of  the  right  lung  and  l^ronchial  lymphatic  glands,  acute  degen- 
eration of  the  kidneys. 

Diagnosis. — Acute  yellow  atrophy  of  the  liver. 


TA15I>E    XXI. — Jaundice.     Sii^ns  and  Symptoms. 


Causes. 


Sepsis 


Favoring        I       Accompanying  Constitutional  R    1'  f 

conditions.       ]         signs  ( local).  manifestations. 


Severe  I  )epends  on  type  .    '       '      ■,      -  1  )rainaKe. 

infection.  of  infection.  ,  •^'■11  "''a     "   ' '  J'"":. 

Chills.      .Anemia. 


(lall-stones     .    . 


Hiliarv  CO  ic,  often.  , .,  .,,         ,  i>  c 

f   .     1  I         .  i-       1  c  (  hi    s,   often.  1  .issace  ol 

tat  olil  women.       1  enderness,  often.  ,  ,  '^ 

lyplu.id.  Knlai-ced  gall-  fever,  otl.-n.  ,,^"'"f.- 

^'  1,     ,  , '^        ,-  f.niaciatiMii.  oUen.  Oijeration. 

bladder,   olteii.  ' 


"  Cat.irrhal  jaundice' 


Sometimes 
enl.irned  livei 


I  leiiressioii.  Toiiii-    (under 

Slow  pulse.  six  weeks  I. 


I'revious 
gastric  canci 


r.nlarged  nodulai 

livci.      (iasiric 

minor  I?;. 


l-'.nuu  iation. 
l-ever.      .Vneiiii; 


( 'irrliosis  of  liver 


liver  usuallv  en- 

lar(.;ed.       I'ortal 

stasis.      Splenic 

minor. 


'.nuuiaticn 
.\nenii.i. 


Tapping; 

()pe,aU..M'l 


(.  anccr  <'f  hile-diicts  and   gall-        ,  .  ,  ,, 

I  1     I  1  1  I.aler  middle  ,,■  n  1  ■     1  1 

bladder,    pancreas,    or    duo  ,.  llig  gall-hiadder. 

drnum 


Kniai  iatii.n. 
Anemia. 


CHAPTER  XXIII 

NERVOUSNESS 

The  uses  of  this  word  are  so  vague  and  various  that  one  may  be 
seriously  misled  unless  one  cross-questions  the  patient  as  to  just  what 
he  means  when  he  calls  himself  "nervous."  Thus,  for  example,  ner- 
vousness may  be — 

(a)  Motor,  wholly  or  largely.  The  patient  may  have  what  is 
called  ''the  fidgets,"  and  be  unable  to  keep  still  or  to  control  the  motions 
of  some  part  of  his  body,  as  in  Sydenham's  chorea,  or  in  the  habit 
choreas  and  muscular  twitchings  so  common  in  neurotic  people.  The 
tremors  of  general  paralysis  or  hyperthyroidism  are  sometimes  referred 
to  by  the  patient  as  "nervousness." 

(b)  Sensory.  When  people  start  at  any  slight  noise  or  jar,  when 
they  are  abnormally  sensitive  to  light,  to  odors  and  tastes,  they  often 
speak  of  themselves  as  "nervous." 

(c)  Psychic.  Perhaps  the  commonest  usage  of  the  word  "nervous- 
ness" is  in  connection  with  a  variety  of  predominantly  psychic  mani- 
festations, such  as  lack  of  self-control,  emotionalism,  fearfulness,  cause- 
less and  transient  depression,  irritability,  and  the  sense  of  unreality  in 
things. 

(d)  Visceral  and  secretory  neuroses  often  occur  in  connection  with 
one  or  another  of  the  types  above  mentioned,  and  may  constitute  the 
most  prominent  part  of  the  clinical  picture,  but  they  are  not  apt  to  be 
referred  to  by  the  patient  as  "nervousness."  The  patient  is  more  apt 
to  believe  them  due  to  some  more  or  less  serious  organic  disease. 

Interpretation  of  Nervousness. — The  most  important  point  is 
that  identical  nervous  symptoms  may  occur  with  or  without  organic 
disease  behind  them.  A  patient  whose  underlying  malady  is  arterio- 
sclerosis or  chronic  glomerulonephritis  may  yet  present  t}-pical  symptoms 
of  hysteria  or  neurasthenia,  and  the  latter  are  so  insistent  and  so  irritat- 
ing that  we  are  apt  to  neglect  a  thorough  search  for  something  else  in 
the  background. 

Mistakes  are  especially  apt  to  occur  in  persons  o^'er  forty  years  of 
age.  When  ner\'ousness  of  any  type  has  appeared  for  the  first  time 
after  the  fortieth  year  in  a  patient  who  has  never  previously  shown 

730 


NERVOUSNESS 


731 


anything  of  the  sort,  a  diagnosis  of  neurasthenia  or  hysteria  usually 

turns  out  wrong  or  seriously  insufficient  and  leads  us  to  give  a  faulty 
prognosis  and  to  misdirect  our  treatment. 

In  younger  persons  nervousness  is  often  falsely  treated  as  the  com- 
plete diagnosis  when,  in  fact,  it  is  merely  an  expression  of  an  under- 
lying pulmonary  tuberculosis.  A  great  many  of  the  cases  of  nervous 
dyspepsia  and  of  pallor  miscalled  "anemia"  turn  out  to  be  the  earliest 
manifestations  of  tuberculosis. 

Other  types  of  mistake  will  be  exemplified  in  the  cases  to  follow. 

Case  378 

A  Russian  housemaid  of  twenty-four,  with  a  good  family  history, 
was  first  seen  April  27,  1907.  She  has  never  been  strong.  She  has 
suffered  from  headaches  and  dysmenor- 
rhea for  the  past  seven  years.  These 
pains  just  now  are  not  so  troublesome  as 
formerly.  Of  late  she  has  been  weak, 
faint,  and  worn  out.  Two  weeks  ago  she 
was  operated  upon  for  hemorrhoids  at 
the  Boston  City  Hospital.  Since  that 
time  she  has  had  a  great  deal  of  nervous- 
ness with  pain  scattered  throughout  various 
parts  of  her  body  ("Schmerzen  Uberall"), 
pressure  about  the  heart,  eructations  of 
gas,  dryness  of  the  mouth,  and  the  fre- 
quent discharge  of  pale  urine.  Her  ap- 
petite is  rather  poor,  the  bowels  regular. 
The  patient  has  a  cyanotic  look.  At 
entrance  to  the  hospital  her  "cribbing," 
nervous  vomiting,  convulsive  chills,  and 
moans  disturbed  tlie  whole  ward.  \'is- 
ceral  examination  was  negative.  The  course  of  the  tem])eraturc  is 
seen  in  the  accompanying  chart. 

Discussion. — Oljviously,  we  are  dealing  with  a  ])sychoniur()>is, 
but  are  wc  sure  that  there  is  nothing  l)ehind  il?  \\'c  are  told  that 
visceral  examination  is  ncgati\c,  l)ut  \isccral  examination  i--  not  alw  ays 
takt-n  to  include  a  study  of  the  Ijlood  and  urine.  Among  the  ]to>^ili!litic'> 
which  could  l)c  eliminated  only  by  such  a  study  are  the  following: 

(a)   Chlorosis. 

(h)   Trichiniasis. 

(t)    Tuberculosis,  ])erhaps  involving  the  genito  urinary  tract. 


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194.—  Chan  of  (  ast-  37S. 


732  DIFFERENTIAL   DIAGNOSIS 

(<f)  Nephritis. 

(e)   Hyperthyroidism  (Graves'  disease). 

(J)    Diabetes. 

(g)  Chronic  poisoning  by  acetanilid  or  other  drugs. 

Chlorosis  might  give  very  similar  symptoms,  but  it  was  here  easily 
excluded  by  the  blood  examination. 

Trichiniasis,  suggested  by  the  wide-spread  pain,  was  not  positively 
to  be  excluded,  as  no  search  was  made  either  in  muscle  or  venous  blood 
for  the  embryo  trichinella.  The  blood  showed  no  eosinophilia  and  we 
were  diverted  from  following  this  hypothesis  any  further  because  another 
and  commoner  disease  soon  appeared  as  a  cause  for  the  symptoms. 

The  urine  showed  nothing  to  justify  any  suspicion  of  genito-urinary 
tuberculosis.  Pulmonary  tuberculosis  may  certainly  exist  for  a  con- 
siderable period  in  the  lungs  without  our  having  any  definite  evidence 
of  it.  In  the  present  case  we  could  find  no  such  evidence,  though  we 
could  by  no  means  exclude  the  earlier  "silent"  stages  of  the  disease. 

Nephritis,  drug-poisoning,  and  hyperthjToidism  were  easily  excluded 
by  a  study  of  the  history,  blood,  and  urine. 

As  soon  as  the  urine  was  tested  for  sugar  we  came  upon  the  object 
of  our  search,  the  cause,  to  all  appearances,  of  the  patient's  "nervous- 
ness." 

Outcome.— The  urine  was  40  ounces  in  twenty-four  hours  at  the  time 
of  entrance;  specific  gravity,  1028;  4.1  per  cent,  of  sugar;  0.2  albumin; 
in  the  sediment  much  pus,  no  casts.  She  was  given  paraldehyd,  '> 
dram,  twice  a  day,  sodium  bromid,  20  grains  three  times  a  day,  and  Ijy 
May  2d  was  much  quieter  and  said  she  felt  better  than  for  months, 
though  she  still  cribbed.  Under  an  antidiabetic  diet  the  urine  was 
freed  from  sugar  in  eight  days;  the  weight  increased  from  112  to  121, 
and  the  reactions  for  acetone  and  diacetic  acid  were  present  for  the 
first  week  of  treatment  and  as  long  as  any  carbohydrates  remained  in 
the  diet,  disappeared.  Her  speech  and  nervous  control  greatly  im]3roved, 
and  by  the  nineteenth  of  May  she  seemed  like  a  different  person,  sleeping 
soundly  without  any  hypnotic,  and  perfectly  content  with  her  diet. 
She  was  allowed  to  go  home  on  the  twenty-second  of  ]\Iay,  the  urine 
])eing  free  from  albumin  and  sugar,  though  remaining  distinctly  increased 
in  amount— 80  to  no  ounces  on  the  average.  The  gain  in  weight  was 
8  pounds  in  sixteen  days. 

The  question  might  be  asked:  "Are  we  dealing  here  with  diabetes 
or  merely  with  glycosuria?"  Since  the  distinction  is  wholly  one  of  time, 
only  the  outcome  can  furnish  us  with  the  answer  to  this  question. 
Acetone   and  diacetic  acid  appear  much  more  frequently  in  the  long- 


NERVOUSNESS  733 

standing  glycosurias,  which  we  call  diabetes,  than  in  the  transient  form. 
There  is  no  doubt  that  neurotic,  high-strung  people  are  more  often 
the  subject  of  temporary  glycosurias  than  are  the  more  phlegmatic 
members  of  the  community.  On  the  other  hand,  the  nervousness  may 
well  be  symptomatic,  the  result  rather  than  the  cause. 

It  will  be  noted  that  much  pus  was  found  in  the  urinary  sediment. 
Such  a  datum  should  always  be  followed  up,  and  the  first  thing  to  do  is 
to  make  sure  that  the  pus  comes  from  the  urine  and  not  from  the  vaginal 
secretions.  In  the  present  case  a  specimen  of  urine  drawn  by  catheter 
was  found  to  be  free  from  pus  on  the  same  day  when  the  specimen 
spontaneously  passed  had  contained  it.  Accordingly,  no  further  investi- 
gation was  made,  and  as  the  glycosuria  improved,  the  pus  disappeared. 

Diagnosis. — Diabetes  mellitus. 

Case  379 

A  married  Irish  woman,  forty  years  old,  with  an  excellent  family 
history,  entered  the  hospital  September  17,  1907.  She  has  l^een  nervous 
all  her  life,  especially  since  her  seventeenth  year.  She  is  very  easily 
worried  or  frightened,  and  has  many  weak  spells.  Last  winter  she  felt 
underneath  her  right  breast  and  in  the  right  l:)ack  a  pain,  which  was 
sharp  on  deep  breath.  This  lasted  a  month.  W^hen  nervous,  she  cries 
very  easily.  She  has  been  married  twenty-three  years  and  has  had  nine 
children.  Her  last  period  was  nine  months  ago.  She  takes  about  six 
cups  of  tea  a  day,  but  no  alcohol.  Since  her  husband  was  admitted  to 
the  Massachusetts  Hospital  last  January  she  has  been  much  overworked, 
taking  boarders  and  caring  for  her  children.  For  the  past  two  months 
she  has  been  especially  nervous,  and  felt  more  tired  in  the  morning 
than  at  night.  She  has  slept  very  little,  and  her  food  has  seemed  to  stop 
at  the  bottom  of  her  breastbone  and  to  lie  there  as  a  heavy  load.  For 
the  past  week  she  has  vomited  everything  that  she  has  taken,  though 
her  diet  has  been  reduced  to  milk  and  weak  tea.  Of  late,  she  has  had 
no  pain  anywhere  exce])t  a  tired  ache  between  her  shoulderl)lades. 
Her  a])])etite  is  fair;  the  l)owcls  move  once  or  twice  a  day.  When 
nervous,  she  passes  urine  very  frccjuently.  For  the  past  two  months 
she  has  had  a  slight  cough  with  a  little  wliite  sputum. 

On  ])hysical  examination  the  ])upils  are  somewhat  irregular,  but 
react  normally.  The  tongue  comes  out  straight,  but  has  a  marked 
coarse  tremor.  The  throat  is  reddened  and  atro])hic;  the  heart  is 
negative,  except  for  a  sliglit  accentuation  of  the  aortic  second  sound. 
The  lungs  are  negative,  sa\e  for  slightly  higher-])ilc-he(l  respiration  at 
the  left  apex  and  occasional  scattered  rales  througliout.     The  abdomen 


734  DIFFERENTIAL   DIAGNOSIS 

is  held  rather  stiffly,  but  is  otherwise  negative,  save  for  a  swelling  extend- 
ing from  the  left  anterior-superior  spine  to  the  neighborhood  of  the 
symphysis,  and  giving  a  marked  impulse  on  cough.  It  is  easily  reduci- 
ble by  pressure. 

Discussion. — As  this  woman  has  had  no  menstruation  for  nine 
months  and  is  obviously  not  i)regnant,  our  first  thought  is  that  the 
symptoms  may  be  due  to  the  menopause,  that  very  convenient  but 
dangerous  explanation  for  such  a  multitude  of  heterogenous  symptoms. 
Such  a  diagnosis  should  never  be  made  until  every  other  reasonable 
alternative  has  been  excluded.  Moreover,  the  vasomotor  symptoms 
usually  present  as  a  part  of  any  disturbance  dependent  upon  the  meno- 
pause are  not  at  all  marked  in  this  case.  Only  the  nervous  frequency 
of  urine  suggests  them. 

It  was  the  fashion,  a  few  years  ago,  to  explain  a  great  number  of 
debilitated  conditions  as  the  result  of  the  abuse  of  tea,  especially  when 
the  physician  was  able  triumphantly  to  point  out  that  the  patient  kept 
the  tea-pot  on  the  stove  continuously  and  took  a  "nip"  every  now  and 
then  throughout  the  day,  thus  getting  the  full  benefit  of  a  strong  decoc- 
tion ot  tannin.  In  the  eleven  years  of  out-patient  service  involving 
four  years  of  female  medical  clinic  I  have  seen  less  than  half  a  dozen 
cases  in  which  the  symptoms  appeared  to  me  due  to  the  abuse  of  tea. 
Doubtless  it  often  does  harm  by  taking  the  place  of  food,  and  in  the 
present  case  this  is  distinctly  suggested.  Overwork  may  likewise  have 
been  a  factor  in  her  breakdown. 

The  hypotheses  suggested  in  the  last  paragraph  cannot  be  definitely 
refuted,  but  against  them  the  following  consideration  may  be  urged. 
The  overwork  and  the  tea-drinking  have  lasted  for  many  years,  the 
symptoms  for  less  than  one  year.  Why  should  the  breakdown  have 
come  just  at  this  time,  after  the  patient  had  borne  lier  overwork  and 
faulty  habits  for  so  many  years  without  apparent  detriment?  Some 
new  and  determining  factor  must  have  come  into  the  case — the  same 
factor,  I  believe,  which  accounts  for  most  of  the  seemingly  causeless 
dyspepsias  and  run-down  conditions  which  we  are  a])t  to  attribute  to 
this  or  that  food,  overstrain,  or  a  surgical  lesion.  In  a  large  number  of 
these  cases  tuberculosis  later  makes  itself  obvious;  in  many  others,  I 
believe,  it  is  contjucrcd  by  the  patient's  own  vitality,  while  we  think  we 
are  curing  his  dyspepsia  or  his  "del)ility"  with  one  or  another  remedy. 

The  pulmonary  signs  in  this  case  are,  indeed,  very  slight.  If  ]^re- 
cisely  tlie  same  signs  were  present  at  the  right  apex,  one  could  not,  witli 
confidence,  attribute  any  meaning  to  them;  but  at  the  left  apex  even  the 
slightest  abnormalities  are  of  importance  if  unaccounted  for  by  any 


NERVOUSNESS  735 

pathologic  condition  of  the  heart  or  abdominal  organs.  Even  signs 
so  slight  as  this  should  make  us  follow  the  patient  very  carefully  and 
examine  the  lungs,  the  sputa,  and  the  temperature  chart  for  confirma- 
tory evidence.  If,  after  we  have  done  our  best  by  such  an  examination, 
the  condition  of  the  lungs  seems  still  doubtful,  and  no  other  diagnosis 
has  in  the  mean  time  suggested  itself,  we  should  always  treat  the  case  as 
tuberculosis. 

Outcome. — For  some  days  no  sputum  could  be  obtained,  but  in  the 
first  satisfactory  specimen  tubercle  bacilli  were  demonstrated.  The  in- 
guinal hernia,  present  on  the  left  side,  was  fairly  well  held  up  by  a  truss. 

Diagnosis. — Phthisis. 

Case  380 

A  telephone  girl  of  eighteen  entered  the  hospital  September  21.  1907. 
One  brother  of  fifteen  is  said  to  have  consumption.  Two  grandfathers 
and  one  grandmother  died  of  consumption,  the  last  one  ten  years  ago. 
The  patient  has  always  been  strong  and  healthy.  She  had  tyj)hoid 
fe\'er  eight  years  ago,  measles  four  years  ago,  followed  by  a  mastoid 
oj)eration.  Her  hearing  is  excellent.  Her  menstruation  has  l)cen 
irregular  for  the  j)ast  two  or  three  years,  and  painful,  so  that  she  has  to 
be  in  bed  two  or  three  days  each  month.  She  has  recently  been  in 
the  surgical  wards,  and  has  been  curetted. 

Since  early  childhood  she  has  had  a  poor  appetite,  constipation, 
distress,  and  burning  stomach  without  regard  to  the  character  of  food 
or  the  time  of  taking  it.     She  has  sick  headaches  every  two  to  fi\e  ^\■eeks. 

Eight  weeks  ago  she  fainted  when  she  got  up  in  the  morning,  and 
did  not  work  that  day.  After  working  the  next  day  she  took  to  bed, 
where  she  has  remained  since,  vomiting  almost  every  fifteen  minutes, 
day  and  night  (?).  Rectal  feeding  has  l)een  carried  out.  She  b.as  no 
definite  ])ain,  but  her  vomiting  is  ])receded  by  a  burning  sensation  at 
the  epigastrium.  For  the  last  three  days  there  has  l)een  partial  loss  of 
vision.  She  cannot  recognize  ])ersons  or  see  more  than  their  outlines. 
There  has  also  been  gradual  loss  of  ambition  and  slowness  of  s])eech. 

On  examination  the  ])atient  is  fairly  nourished,  the  skin  dry  and 
harsli,  tlie  ])upils  widely  dilated,  but  reacting  normally.  The  clust 
and  abdomen  show  nothing  abnormal.  An  attempt  \\'as  made  to  ])a--s 
a  stomach-tube,  but  the  patient  struggled  ^■i()lentlv  and  ])ulle(l  it  out. 
It  was  finally  re])lace(l,  and  fasting  contents,  consisting  of  nuuu>  and 
white  froth,  o1)tained;  no  food.  After  a  test-meal  there  was  no  free 
\IC\  l)y  any  test,  no  lactic  acid,  and  no  l)l()od.  Infiation  >howed  that  the 
stomach  was  not  in  anv  wav  enlartrfd. 


736  DIFFERENTIAL  DIAGNOSIS 

Examination  of  the  fundus  showed  an  optic  neuritis  in  the  right  eye, 
numerous  small  hemorrhages  about  the  disc,  and  one  large  one  near  the 
nerve  in  the  left  eye.  The  urine  was  entirely  negative,  likewise  the 
blood. 

During  the  first  two  days  after  admission  the  patient  vomited  four  or 
five  times,  after  that  very  rarely,  the  vomitus  consisting  of  colorless 
mucus.  Salt  solution,  8  ounces  every  six  hours,  was  well  retained  by 
rectum,  and  the  skin  soon  began  to  be  less  dry.  After  this  the  patient 
took  milk  and  lime-water  in  small  amounts  for  the  first  few  days,  after 
that  cereals  and  gruels.  By  October  ist  eggs  were  added,  and  by  the 
tenth  she  was  taking  plenty  of  all  sorts  of  food  and  the  enemata  were 
omitted. 

On  October  ist  the  patient  complained  of  numbness  below  the 
waist,  later  of  numbness  over  the  whole  body,  but  there  was  no  diminu- 
tion of  the  pain  sense.  She  had  one  hysteric  attack,  with  tremor  of  the 
muscles,  following  rigidity  and  slight  opisthotonos.  The  patient 
seemed  irrational  and  fretful,  at  times  spoke  very  slowly.  Her  vision 
was  restored  by  the  sixth,  and  her  appetite  was  then  excellent.  She 
seemed  in  a  very  pleasant  state  of  mind,  constantly  expressing  her 
gratitude  to  the  nurses. 

On  the  ninth  of  October  a  tumor  was  noticed,  rising  above  the 
pubes  almost  to  the  umbilicus.  A  catheter  was  introduced,  and  85 
ounces  of  high-colored  urine  with  a  heavy  sediment  was  withdrawn. 
Eleven  hours  later  59  ounces  of  urine  were  withdrawn.  At  this  time  she 
said  that  she  was  unable  to  move  her  legs,  and  had  to  be  turned  in  bed. 
Soon  after  she  had  involuntary  defecation.  On  the  thirteenth  she  was 
somewhat  improved,  but  said  she  could  not  speak  above  a  whisper. 
About  that  time  a  rectovaginal  fistula  developed.  Vomiting  began 
again  on  the  seventeenth  of  October,  and  was  accompanied  by  cyanosis 
and  difficult  respiration.  The  same  day  tracheal  rales  were  audible. 
She  seemed  too  weak  to  clear  them. 

Under  strychnin,  ^  grain,  and  atropin,  yuo  grain,  this  attack  passed 
off  and  she  breathed  normally,  though  she  continued  to  vomit  in  small 
amounts  and  the  pulse  was  not  of  good  quality. 

Seen  by  a  neurologic  consultant  on  the  seventeenth  of  October,  the 
diagnosis  was  hysteria  plus  some  toxic  process. 

Discussion. — The  advent  of  marked  slowness  of  speech  is  an 
unusual  symptom,  which  should  always  attract  our  attention.  It 
occurs  in  myxedema,  in  many  depressed  and  melancholic  states,  in 
multiple  sclerosis,  and  occasionally  in  hysteric  states.  In  multiple 
sclerosis  it  is  apt  to  be  associated  with  nystagmus,  increased  reflexeS; 


NERVOUSNESS  737 

and  intention  tremor,  none  of  which  is  present  here.  This  girl  was 
rarely  depressed  or  hysteric,  and  showed  none  of  the  cutaneous  or  mental 
symptoms  of  myxedema. 

The  stomach  symptoms  were  very  marked  and  had  led  to  a  diag- 
nosis of  gastric  ulcer  before  she  entered  the  hospital.  The  quick  clearing 
up  of  the  gastric  symjjtoms  under  treatment,  howe^•er,  and  the  absence 
of  any  gastric  or  rectal  hemorrhage  and  of  any  e\'idcnce  of  stasis,  makes 
it  obvious  that,  at  all  events  at  the  present  time,  her  chief  sufferings  are 
not  due  to  that  cause. 

Hysteria  naturally  occurs  to  our  minds  in  a  patient  who  has  muscular 
tremor  and  opisthotonos,  is  fretful  and  irritable,  and  has  a  great  deal 
of  unaccountable  vomiting.  But  the  condition  of  the  fundus  oculi 
cannot  be  thus  explained,  despite  the  dictum  of  the  neurologic  consultant. 
What,  then,  is  the  cause  of  the  optic  neuritis  and  retinal  hemorrhages? 

Brain  tumor  might  account  for  her  vomiting  and  for  the  psychic 
disturbances.  We  should  expect,  however,  to  find  headache,  vertigo, 
and  focal  disturbances  of  some  kind  (localized  paralysis,  spasm,  anes- 
thesia, a])hasia  of  some  type,  astereognosis) . 

Of  meningitis  we  have  no  important  evidence,  and  there  is  nothing 
in  the  case  definitely  to  suggest  syphilis. 

Nephritis  is  the  only  other  common  cause  of  retinal  hemorrhage, 
with  or  without  optic  neuritis,  Ijut  of  this  neither  the  heart  nor  the  urine 
gave  us  at  the  outset  any  hint.  Later  the  urine  was  so  constantly  in- 
voluntary that  none  was  collected  for  examination.  In  the  light  of  the 
outcome  it  would  ap])ear  that  sucli  an  examination  might  ha\c  l^ccn 
of  the  greatest  im])ortance. 

Outcome. — A  few  days  after  this  she  began  to  haAe  fever  ranging 
from  99°  to  ioi°  P.,  and  continuing  until  the  day  of  her  death,  October 
27th.  Autopsy  showed  a  clironic  nejjhritis  with  su])})uration,  an 
extensive  br()nch()])ncum()nia,  and  an  obsolete  tuberculosis  of  the  mesen- 
teric l)'mj)h-glands.     Tlie  stomach,  brain,  and  cord  were  normal. 

This  case  is  one  of  those  which  have  most  strongly  im])ressed  upon 
me  the  dangers  lurking  in  the  diagnosis  of  "hysteria."  It  is  the  fourth 
case  that  1  liave  known  to  die  \\ith  this  diagnosis.  In  two  of  these 
absolutely  nothing  was  found  ])ostmortem,  and  in  these  we  might,  if 
we  were  so  inclined,  consider  the  diagnosis  ^•eri^lccl.  Ikit  when  we  say 
"hysteria,"  we  ordinarily  Jiiean  a  disease  which  cannot  in  itself,  and 
a])art  from  starvation  (as  in  anorexia  nervosa),  ])r()\e  fatal.  To  niy  mind 
these  cases  simply  indicate  some  of  the  blind  s{)ots  in  our  diagnostic 
retina. 

Diagnosis. — Supj)urati\e  nephritis. 

17 


738  DIFFERENTIAL   DIAGNOSIS 


Case  381 


A  widow  of  sixty,  first  seen  October  9,  1907,  has  been  treated  in 
the  out-patient  department  of  the  hospital  for  some  time  under  the 
diagnosis  of  neurasthenia.  She  has  always  been  a  healthy  woman, 
except  that  she  has  had  eight  miscarriages,  attributed  by  her  to  horse- 
back riding  during  pregnancy.  She  has  five  living  children,  all  healthy. 
Last  autumn  she  had  an  attack  of  diarrhea  and  vomiting,  and  was  in 
the  Chelsea  Hospital  for  a  week.  Since  that  time  she  has  been  more  or 
less  run  down.  In  IMarch,  1907,  she  fell  into  a  hole  in  the  floor,  bruising 
her  foot  and  right  side,  and  since  that  time  has  had  occasional  pains  in 
the  right  side  of  the  chest,  sometimes  severe  enough  to  make  her  leave 
off  her  corsets.  For  the  past  seven  weeks  she  has  had  a  great  deal  of 
nausea  and  has  been  extremely  nervous.  Five  weeks  ago  she  was 
examined  in  the  out-patient  department  and  told  that  she  was  "  simply 
nervous^  A  week  later  her  right  chest  was  tapped,  and  2h  quarts  of 
bloody  fluid  withdrawn.  An  equal  amount  of  the  same  character  was 
removed  six  days  later. 

On  examination  the  patient  was  excellently  nourished,  slightly  obese, 
the  face  flushed,  the  mucous  membranes  of  good  color;  the  lips  and 
finger-tips  somewhat  cyanotic.  The  heart's  impulse  was  in  the  eighth 
interspace,  behind  the  anterior  axillary  line,  6J  inches  to  the  left  of  mid- 
sternum.  The  right  border  could  not  be  determined.  The  sounds  were 
normal.  The  whole  right  chest  was  dull,  with  flatness  in  the  lower  half, 
and  rapid  and  shallow  respiration.  Breath-sounds  were  very  indistinct, 
vocal  and  tactile  fremitus  absent,  except  at  the  apex.  The  left  lung 
seemed  to  be  normal.  Physical  examination  was  otherwise  negative, 
including  blood  and  urine.  The  chest  was  at  once  aspirated,  and  no 
ounces  of  bloody  fluid,  with  a  specific  gravity  of  1019,  was  removed. 
Differential  count  of  the  sediment  showed  hmphocytes,  97  per  cent., 
endothelial  cells,  3  per  cent.  No  tubercle  bacilli  could  be  found  in  the 
sediment  of  the  digested  clot.  Under  ordinary  culture-media  the  fluid 
remained  sterile,  and  in  a  guinea-pig  10  minims  of  the  sediment  pro- 
duced no  disease  in  six  weeks.  In  four  days  the  fluid  had  reaccumulated, 
and  tapping  had  to  be  repeated  about  every  four  days  until  November 
9th. 

Discussion. — But  for  this  patient's  age,  it  would  be  natural  to 
assume,  after  reading  the  history  and  previous  to  the  physical  examina- 
tion, that  we  are  dealing  with  a  traumatic  neurosis  which  originated 
in  the  accident  of  March,  1907.  In  my  judgment,  however,  it  is  always 
unwise  to  make  a  diagnosis  of  any  type  of  neurosis  when  the  symptoms 


NERVOUSNESS  739 

arise  first  after  the  fiftieth  year.  I  have  never  known  such  a  diagnosis 
confirmed.  The  mental  characteristics  of  this  patient  were,  indeed, 
very  much  those  which  we  associate  with  the  neuroses,  but  diagnoses 
based  upon  mental  characteristics  alone  are  always  most  vulnerable, 
even  within  the  field  of  the  alienist,  still  more  markedly  so  outside  it. 

After  the  chest  was  tapped  we  assumed  that  the  patient  was  sulTering 
from  a  pleural  effusion  of  the  ordinary  (i.  e.,  tuberculous)  type.  Even 
in  advance  of  our  own  physical  examination,  however,  we  ought  to  have 
suspected  that  something  more  serious  was  in  the  background.  Ordinary 
tuberculous  effusions  (/.  e.,  99  per  cent,  of  all  the  serous  effusions  which 
we  meet  with)  are  rarely  bloody,  and  very  rarely  reaccumulate  within 
six  days.  One  tapping  suffices,  in  the  vast  majority  of  cases,  and  bloody 
fluid  does  not  suggest  tuberculosis,  despite  the  oft-copied  statement  of 
many  text-books. 

The  age  of  the  patient  and  the  rapid  reaccumulation  of  the  bloody 
fluid  should  have  suggested  to  us  at  once  the  diagnosis  of  malignant 
disease  involving  the  pleura,  lungs,  or  mediastinal  glands. 

Doubtless  there  was  a  period  (before  any  fluid  had  accumulated) 
when  diagnosis  was  difficult  or  impossible,  and  when  the  psychic  pecu- 
liarities were  sufficient  to  exi)lain,  though  not  to  excuse,  the  diagnosis  of 
neurosis.  At  this  ])criod  our  i)roi)er  attitude  would  have  been  expressed 
by  saying,  "We  do  not  know." 

Outcome. — The  .Y-ray  showed  a  diffuse  shadow  over  the  whole 
right  side,  and  an  unexplained  mass  near  the  hilum  of  the  left  lung. 
The  patient  had  frequent  dyspnea,  more  or  less  relieved  by  morphin, 
amyl  nitrite,  and  oxygen. 

Autopsy  showed  endothelioma  of  the  ]:)lcura,  with  extension  into 
the  lungs,  pericardium,  diaphragm,  right  thoracic  wall,  bronchi,  and 
retroperitoneal  lym])hatics,  liver,  stomach,  and  left  adrenal;  acute  sero- 
fibrinous ])ericarditis  and  general  arteriosclerosis. 

Diagnosis. — (See  last  ])aragraj)h.) 

Case  382 

A  housewife  of  lliirty-three  was  llrst  seen  Xoveml)er  4.  1Q07.  She 
lias  lost  one  sister  of  consumption.  Her  family  history  was  otherwise 
excellent,  and  she  had  never  been  ill  except  that  four  years  ago  she  had 
l)lo()d-poisoning  after  childbirth,  but  reco\ered  entirely  in  three  months. 
I'ifteen  months  ago  she  ga\"e  birth  to  a  child  after  a  nomial  hilxir.  Slie 
felt  unusually  well  during  the  pregnancy.  Immediately  after  >he  became 
\ery  nervous,  with  spells  of  trembling  and  restlessness  la-^linL:  an  hour, 
once   or   twice  a   day.     These   symntonis   persi>le(l   until    four   months 


740 


DIFFERENTIAL   DIAGNOSIS 


later;  the  child,  who  had  been  doing  excellently  well  at  the  breast,  had 
to  be  weaned.  During  this  period  she  also  had  severe  burning  micturi- 
tion, but  since  the  weaning  of  the  child  this  has  not  troubled  her.  Four 
months  ago  she  ate  a  considerable  quantity  of  green  corn,  and  was  ai 
once  attacked  with  diarrhea,  four  or  five  green  watery  movements  a 
day  and  five  or  six  at  night.  This  diarrhea  persisted  until  two  weeks 
ago,  when  it  was  diminished  by  medicine,  and  for  the  past  two  days  her 
bowels  have  not  moved.     She  has  been  in  bed  for  the  past  five  weeks, 

complaining  chiefly  of  dizziness,  weakness, 
rumbling  in  her  head,  and  dryness  of  the 
mouth.  For  two  weeks  she  has  had  a 
cough  and  raised  considerable  greenish 
sputa. 

The  course  of  the  temperature  is  seen 
in  the  accompanying  chart  (Fig.  195).   The 
patient  is  pale  and  emaciated,  the  tongue 
moist  and  slightly  excoriated  along  the  an- 
terior edge,  the  mouth   and  throat  other- 
wise normal.     A  systolic  murmur  is  heard 
over  all  the  precordia,  loudest  in  the  pul- 
monary area,   otherwise    the    heart    shows 
nothing  abnormal.     The   lungs,   abdomen, 
and  reflexes  are  normal.     There  is  slight 
spinal  curvature  in  the  dorsal   region,  with 
a  concavity  toward  the  left.      Examination 
of  the  sputa  shows  nothing  abnormal.     The 
same  is  true  of  the  urine. 
Discussion. — The  family  history,  the  spinal  curvature,  the  fever, 
greenish  sputa,  and  painful  micturition  might  be  taken  as  hints  of  a 
tuberculous  infection,  though  its  localization  is  not  clear,  and  nothing 
in  the  further  study  of  the  case  gives  sup])ort  to  any  such  hypothesis. 

Acute  endocarditis  might  produce  a  murmur  with  the  characteristics 
here  described,  although  it  is  much  more  common  to  find  it  in  the  mitral 
or  aortic  area.  Especially  when  fever,  without  known  cause,  is  present, 
any  cardiac  murmur  must  be  thought  of  in  the  light  of  a  possible  endo- 
carditis. Yet  in  this  case  we  cannot  ad\ance  beyond  the  stage  of  con- 
jecture with  such  a  diagnosis,  as  we  ha\"e  nothing  but  the  facts  just 
mentioned  by  which  to  support  it.  Leukocytosis,  evidences  of  peri- 
pheral cml)olism,  tender  fingcr-pcids  (Osier),  marked  urinary  abnormali- 
ties, chills,  and  sweats  are  all  absent. 

Doubtless  if  this  ];aticnt  had  been  of  the  male  sex,  the  diagnosis 


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,  NERVOUSNESS  74I 

would  have  been  much  earlier  suspected.  Her  recent  labor,  and  the 
rather  indefinite  ill  health  which  we  are  accustomed  to  tolerate  in  many 
women  at  such  a  time  without  feeling  obliged  to  make  a  diagnosis, 
probably  prevented  her  physician  from  thinking  earlier  of  the  importance 
of  a  blood  examination,  the  tell-tale  indications  of  which  are  revealed 
in  the  outcome. 

Outcome. — The  blood  showed  red  cells,  640,000;  white  cells,  6500; 
hemoglobin,  13  per  cent.  A  differential  count  of  200  white  cells  showed 
polynuclears,  57  per  cent.;  lymphocytes,  43  per  cent.;  two  megaloblasts 
and  one  normoblast  were  seen  during  this  count.  The  red  cells  were 
markedly  oversized,  deformed,  abnormally  stained,  and  stippled.  The 
fundus  oculi  showed  numerous  retinal  hemorrhages.  The  ])atient 
steadily  failed,  and  died  on  the  sixteenth  of  November,  without  any 
marked  change  in  the  symptoms. 

Diagnosis. — The  diagnosis  was  not  in  doubt  after  the  first  blood 
examination,  as  all  the  characteristics  of  pernicious  anemia  were  present. 

Case  383 

An  optician  of  fifty-six  was  first  seen  May  28,  1907.  He  has  lost  one 
brother  of  consumption,  and  his  wife  died  of  the  same  disease.  The 
patient  had  pleurisy  seven  years  ago,  and  was  sick  with  it  for  three  or 
four  days.  Seven  years  ago  he  began  to  have  nervous  de])ression.  and  he 
has  never  been  quite  free  from  it  since.  He  has  had  ])eriods  of  de])res- 
sion  and  despondency,  and  has  been  confined  to  bed  many  times  for 
from  one  to  eight  weeks.  His  habits  are  good.  He  denies  venereal 
disease. 

Ten  days  ago  he  began  to  feel  "all  smashed  u])" — consideral)le 
headache,  nausea  but  no  vomiting,  stiffness  of  the  legs  and  neck, 
shortness  of  breath,  insomnia  (apparently  due  to  nervousness),  and 
moderate  constiT)ation.  His  appetite  has  been  good,  and  he  has  been 
very  anxious  to  make  a  business  trij)  to  Ohio,  but  has  been  prevented 
by  this  present  illness.  Of  late  his  hands  and  arms  have  begun  to 
tremble,  and  his  left  foot  drags  a  little  when  he  walks. 

On  examination,  the  patient  is  well  develoj)ed  and  nourished.  His 
right  ])upil  is  slightly  irregular  and  larger  than  the  left;  both  react 
normally.  The  heart's  a})ex  is  in  the  fifth  s])acc,  just  outside  the  nijiiile- 
line.  I'here  is  no  enlargement  to  the  right.  The  heart- sounds  are  irreg- 
ular in  force  and  rhythm;  no  munnur  or  accentuation.  F)lo(>(i  normal. 
Hlood  ])ressure  is  120  mm.  Hg.  The  lungs  and  alxlomen  are  negatixe. 
In  the  left  axilla  there  is  a  gland  the  si/e  of  a  \\alnut.  The  left  leg  i> 
moxed  with  <i;reat  difficultv.     Sensation  is  exerw.liere  uood.     There  i> 


742  DIFFERENTIAL   DIAGNOSIS  , 

fibrillary  twitching  over  the  arms  and  body,  and  a  coarse  twitching  of 
the  hands  and  face.  The  patient  is  very  sleepy,  but  when  aroused, 
speaks  without  difficulty.  A  neurologic  consultant  said,  "probably 
psychoneurosis,"  but  advised  us  to  continue  observation  before  con- 
cluding that  there  is  nothing  further. 

Discussion. — From  the  family  history,  from  the  previous  attack 
of  pleurisy,  and  from  the  presence  of  an  enlarged  gland  in  the  left  axilla, 
tuberculosis  is  naturally  the  first  cause  for  this  man's  nervousness  which 
we  are  led  to  consider.  Such  a  consideration,  however,  proves  fruitless, 
as  nothing  in  the  physical  examination  bears  it  out. 

Some  cerebral  lesion  was  the  next  thing  that  occurred  to  me  in 
studying  the  case,  especially  in  view  of  the  headache,  the  nausea,  the 
irregular  and  unequal  pupils,  and  the  paresis  of  the  left  leg.  The  mental 
state,  moreover,  was  very  abnormal,  especially  considering  the  age  at 
which  it  first  appeared,  and  the  muscular  tremor  seems  likewise  significant 
of  a  lesion  of  the  central  nervous  system.  Had  the  blood-pressure  been 
high,  we  should  doubtless  have  thought  of  chronic  nephritis  as  soon  as 
the  slight  cardiac  enlargement  was  discovered,  but  the  normal  pulse 
tension  threw  us  at  first  off  the  track. 

We  remained  in  the  dark  regarding  the  diagnosis,  trying  to  figure 
out  some  type  of  thrombosis,  softening,  or  slight  hemorrhage  in  the 
brain  which  could  account  for  the  condition  of  the  left  leg.  Dementia 
paralytica  was  considered,  but  the  mental  state,  the  pupils,  and  reflexes 
were  not  at  all  characteristic  of  this  condition;  nor,  on  the  other  hand, 
were  they  wholly  inconsistent  with  it.  At  this  point  most  of  our  difficul- 
ties were  cleared  up  by  the  receipt  of  a  full  report  upon  the  condition 
of  the  urine,  details  of  which  follow. 

Outcome. — The  urine  averaged  60  ounces  in  twenty-four  hours; 
specific  gravity,  ion;  the  slightest  possible  trace  of  albumin  was  found, 
and  a  rare,  finely  granular  cast.  There  was  marked  soft  edema  of  the 
feet  and  lower  legs.  By  rest  in  bed,  10  minims  of  digitalis  e\ery  four 
hours,  I  ounce  of  magnesium  sulphate  every  morning,  diuretin,  15  grains 
four  times  a  day,  and  limitation  of  liquids,  the  patient  was  greatly  im- 
proved by  the  second  of  June.  By  the  third  the  edema  was  gone.  By 
the  ninth  he  was  sitting  up,  feeling  well,  passing  a  large  amount  of 
urine,  his  heart's  action  much  stronger  and  steadier,  his  leg  motions 
nearly  normal.  On  the  eighteenth  he  was  allowed  to  go  home  in  excel- 
lent spirits. 

Diagnosis. — Chronic  interstitial  nephritis. 


APPENDIX  A 
As  mentioned  in  the   Introduction,  certain   statistical  articles   and 
monographs  were  used  in  the  preparation  of  the  "  gridiron  "  diagrams. 
The  most  important  were  as  follows: 

1.  Rolleston:  "Diseases  of  the  Liver"  (W.  B.  Saunders  Co.). 

2.  Bramwcll:  "Clinical  Studies,"  Jan.  i,  1910,  vol.  viii,  part  ii,  p.  97. 

3.  Garceau:  "Renal  Tumors"  (Appleton,  19 10). 

4.  Howard  A.  Kelly:  "The  Vermiform  Appendix"  (W.  B.  Saunders  Co.). 

5.  Tauquerel  des  Planches:  "Monograph  on  Plumbism,"  Paris,  1839. 

6.  Starr:  "Text-book  of  Diseases  of  the  Nervous  System." 

7.  F.   C.   Shattuck:  "Tuberculous   Peritonitis,"   Trans.   Assoc.   Amer.    Physicians, 
1902,  p.  137. 

8.  Thomas  McCrea:    Article  on   "Typhoid  Fever"  in  vol.  ii  of  Osier's  "Modern 
Medicine." 

9.  Naunyn:  "Klinik  der  Cholelithiasis,"  Lcipsig,  1892. 

10.  Greenough   and   Joslin:  Article  on   "Gastric   Ulcer,"    Boston   Med.   and   Surg. 
Jour.,  Oct.  19,  1899. 

11.  E.  A.  Codman:  "Subdeltoid  Bursitis,"  Boston  Med.  and  Surg.  Jour.,  May  31, 
1906. 

12.  Berger:  "Occupaticm  Neuroses,"  Osier's  "  Modern  Medicine,"  vol.  vii,  p.  793. 

13.  Osier:  .Article  on  ".\neurysm,"  Medical  Chronicle,  1906,  vol.  xi,  p.  69. 

14.  Osier:  Lumlcian  Lecture  on  "Angina  Pectoris,"  Lancet,  March  12,  1910. 

15.  Henry  Phipps'  Institute:  "Annual  Reports"  (1906-1909). 

16.  Musser  and  Norris:  Article  on  "Pneumonia,"  Ostler's  "'  Modern  Medicine,"  voL 

»,  P-  563- 

17.  Dickinson:  "  Uremia,"  in  "  Allljutt's  System,"  1897,  vol.  v,  p.  367. 

18.  Savill:  Lectures  on  "Hysteria,  Etc."  (Wm.  Wood,  1909). 

19.  F.  T.  Lord:  "Diseases  of  the   Pleura,"  Osier's  "  Modern  Medicine,"  vol.  iii,  p, 
780. 

20.  Keyes:  "Diseases  of  the  Genito-urinarv  Organs"  (Ajipleton,  1910). 

21.  Hevan:  "Renal  Tuberculosis,"  Jour.  Amer.  Mifl.  Assoc,  Oct.  9,   1906. 

22.  Albarran:  "Les  Tumeurs  <iu  Rein,"  Paris,   1903. 

23.  Robson  and  Cammidge:    "Diseases  of  the  Panireas." 

24.  Benj.  Tcnncy:  "Renal    and    Iriteral   Calculi,"   Boston  Med.   and   Surg.   Jour., 
June  8,  1905. 

25.  F.  B.  Greenough:  "  Herpes  Zoster,"  Boston  IMed.  and  Surg.  Jour.,  Dec.  5,  1S89. 


APPENDIX  B 


I.  Typhoid  Regfime  at  the  Massachusetts  General  Hospital  (West 

Medical  Service) 

1.  Bed  until  temperature  is  normal. 

2.  Four-hourly  chart. 

3.  Four-hourly  mouth-wash  and  sjjrav. 

7j;5 


744  APPENDIX 

(a)  Swab  tongiic,  cheeks,  and  gums  with  equal  parts  of — 

Boric  acid  (saturated  acjueous  solution),") 

Lemon-juice,  >  on  a  cotton  stick. 

Glycerin,  J 

(b)  Dobell's  solution,  i  part     )  ^  ,      .  , 

y  Spraved  with  an  atomizer, 
uater,  3  parts  ) 

4.  Four-hourly  bath  whenever  temperature  reaches  or  exceeds  102.5°  F.  (by  mouth). 
Baths  are  given  with  water  and  40  per  cent,  alcohol,  ecjual  parts.     Duration,  twcntj 

minutes  (if  reaction  is  good). 

Temperature  of  bath,  90°  F.,  if  mouth  temperature  is  102.5°  F. 
Temperature  of  bath,  85°  F.  "  "  103.0°  F. 

Temperature  of  bath,  80°  F.  "  "  103.5°  F- 

Temperature  of  bath,  75°  F.  "  "  104.0^  F.  or  more. 

5.  Suds  enema  every  second  day,  if  needed. 

6.  Cocoa  butter  to  lips,  p.  r.  n. 

Typhoid  Diet   (as  Introduced  by  Dr.  F.  C.  Shattcjck   in    1897'). 
I.   Break  j  a  St. • 

1.  One  egg  on  a  slice  of  toast  with  butter. 

2.  One  of  the  following  drinks — 

(a)  Milk,  5iv,  with  cream  (20  per  cent.),  oij,  and  milk-sugar,  oss  to  oj. 

{b)  Malted  milk,  ov. 

(c)  Cocoa. 

{d)  Coffee. 

{e)  Mellin's  food. 
II.    10  A.  M.: 

Lemonade,  orangeade,  grape-juice,  or  albumen-water  with  oij,  milk-sugar. 

in.  Dinner: 

1.  Milk,  cream,  and  sugar  mixture  as  above. 

2.  One  of  the  following  solids — 

(a)  Egg  with  toast  and  butter,  as  above. 

{b')   Minced  chicken  with  toast  and  butter,  as  above. 

(c)  Ice-cream. 

(d)  Blanr  mange  or  wine  jelly  with  sugar  and  at  least  5j  of  cream. 
IV.  3  p.  M. : 

One  raw  egg  beaten  up  with  milk,  o'w;  20  per  cent,  cream,  5ss;  and  milk-sugar,  3  j 

V.  Suppe^: 

1.  Milk,  cream,  anrl  sugar  mixture,  as  at  breakfast. 

2.  Baked  ajijileor  banana-whip,  with  oj  cream,  orone-half  slice  of  toast  with  butter. 

VT.   During  the  Xiglit: 

Two  drinks  consisting  of — 

Albumen-water,  I 

Ora[)e -juice,  I      •  ,        .,,  ,  ~c . 

-  ,  with  milk  and  sugar,  5j. 

Lemonade,  1  n     '      j 

Orangeade,  J 

Or, 
Cocoa,  ^ 

Maltefl  milk,  with  milk. 

Chocolate,  \ 

This  diet  sujiplies  about  2()oo  calorics. 

^  F.  C.  Shattuck,  Journal  of  the  Amer.  Med.  Assoc,  July  10,  1897. 


APPENDIX  745 

IL  Regime  for  Cases  of  Peptic  Ulcer — Gastric  or  Duo<JenaI — as  Used 
in  the  West  Medical  Wards,  Massachusetts  General  Hospital 

A.  Rest  in  bed. 

B.  Diet  as  follows: 

1.  For  first  three  days  give  every  two  hours  (when  awake) — 

Milk,  2  ounces,  with  two  pou-dered  scda-cruckers  (2 J  inches  square)  and 
Cane-su;;ar,  i  teaspoonful  (if  relished). 

2.  For  next  two  or  three  weeks  every  two  hours — 

Milk,  6  to  8  ounces,  with  four  powdered  stjda-crackers  and 
Cane-sugar,  J  to  2  teasfxjonfuJs  (if  desired). 

3.  For  next  two  months  (more  or  less)  a  diet  consisting  cf  average  fwrlions  of  the 

following  articles — 
Milk  and  crackers,  as  above. 
Cornmeal  mush  with  cream  and  sugar  or  salt. 
Potato  puree. 

Milk  with  whites  of  2  eggs. 
.Soft  custard. 
Chocolate. 
Pea  puree. 
Water  is  given  according  to  the  patient's  desire. 

C.  For  pain  or  sour  burning  eructation  a  saucer  of  sodic  bicarlx)nate  and  a  sjx)on  are 
put  at  the  Ixjdside  and  the  patient  is  told  to  take  the  soda  in  amounts  sufficient  to  relieve  him. 


APPENDIX  C 
THE   CLASSIFICATION   OF   NEPHRITIS 

Throughout  this  Ixxjk  I  have  adopted  the  classification  used  in  the  autopsy  records 
of  the  Massachusetts  (General  Hosjntal,  and  identical  in  its  main  outlines  with  that 
used  by  Senator  and  l:)y  Councilman.      The  gist  of   it  ai)])ears  to  be  as  follows: 

Leaving  out  of  account  the  acute  destructive  lesions,  such  as  may  be  produced  by 
mercurial  poisoning,  suppurative  nephritis,  etc.,  the  renal  lesions  distinguishable  by  a 
group  of   clinical  and  anatomic  characteristics  are: 

1.  Glomerulo-nephritis,  early  or  late. 

2.  Interstitial   nephritis.' 

The  former  results  from  an  injury  i)rofluced  in  the  glomeruli  bv  some  irritant — 
usuallv  the  i)r)is;)n  of  an  acute  infectious  disease,  such  as  scarlet  fever,  i)neumc)nia,  or 
acute  endocardilis.  luiema,  anemia,  and  often  uremic  manifestations  occur.  In  cases 
lasting  over  six  weeks  there  is  usually  tardiac  hypertroj'h)-.  If  the  iniur\-  to  the  glomeruli 
is  relatively  slight  and  limited  to  a  few,  n-ioverv  takes  place  after  an  acute  or,  rarelv,  a 
subacute  course  of  the  disease.  If  the  injury  is  more  scrious,  the  disease  mav  go  (Ui  in  a 
jatriit  and  well-compensated  form  for  months  (jr  years,  tlnalh'  ending  with  a  burst  of 
■'a(Ute"  symptoms  (edema,  anemia,  uremia,  cardiac  failurei.  In  the  more  ihn,nic 
cases  the  histology  of  the  kidney  and  the  condition  of  the  heart  and  urine  mav  c  loseh- 
rc'Semble  those  of  the  t\!)e  next   to  lie  described. 

Chronic  interstitial  nephritis  is  relativeh-  uncommon,  es])eciall\  in  the-  tirst  half  of 
life-.  The  lesi;insclo  not  apju^ar  to  originate  in  the  glomeruli,  ami  the-  i'-lnnds  of  intact 
glomeruli  are  relativelv  few.  The'  c  hange  ri-|)resents  a  niorc'  generalK  di'-tributed  dis- 
ease whose  cause  is  obscurc',  though  in  iuan\-,  perhajis  most,  cases  ii  seiins  to  be  related 
to  arteriosclerosis. 

'  Ncpt  inc  Uicling  Ciiunc  ilman's  "  ac  utc-  intc-rstitial   lu  j  liriiii.'' 


INDEX 


[Words  and  page  numbers  printed  in  heavy  type  correspond   to  illustrative  cases;  other  words 
and  numbers,  to  minor  discussions.] 


Abdominal  aneurysm,  172 
angina,  165,  169,  182 

cause  of  epigastric  pain,  155 
pain,  26 

causes  of  general,  128 
general,  128 

considerations,  24 
on  diagnosis  of,  286 
tuberculosis,  264 
tumor,  115,  134 

cause  of  general  abdominal  pain,  129 
Abortive  typhoid,  444 
Abscess,  cerebral,  510 
deep  axillary,  334,  484 
"  fixation,"  207 

hepatic,  8g,  230,  231,  318,  462,  475 
ischiorectal,  368,  400,  481 
li\cr.     See  Abscess,  licpalic. 
lung.     See  Abscess,  pulmonary. 
multiple  renal,  111 
perinephric,  8(),  gi,  318,  411 

cause  of  lumbar  pain,  81 
perirectal,  411 

pulmonary,  21S.  462,  566,  579,  589,  594 
renal,  1 1 1 
subdiaphragmatic,  135,  229,  318 

cause  of  riglit  liypochondriac  pain,  204 
tubal,  2T,j!, 

tuberculosis  with,  338 
.\(ctanilid,  40 
.\ii(l  (oxalic)  ])<)is()iiing.  047 
.\ctinomycosis,  320 
.\cuto  yellow  atroplu'  of  liver,  727 
Adams-Stokes'  disease,  435,  492,  518,  520 
Addison's  disease,  535,  571 
.Vdenitis,  31  2 
mesenteric  .  357 
syphilitic,  281 
.Vdcnoma,  simple,  of  ihjroid,  49 
.Xdherenl  jHTicardium,  2i(),  700 
Adhesions,  i)el\ic,  cause  of  left  iliac  i)ain,  276 
of  rigiit  iliac  pain,  259 


Adhesions,  pleural,  185,  301 
pleuropericardial,  185 
pyloric,  174 

cause  of  epigastric  pain,  154 
Adhesive  pericarditis,  51 

chronic,  705 
Adolescence  cause  of  headache,  35 
Air,  bad,  cause  of  headache,  t,^ 
Alcohol  cause  of  headache,  t^t, 
Alcoholic  gastritis,  214 
neuritis,  373,  555,  557 

cause  of  pain  in  legs  and  feet,  351 
Alcoholism,  77,  158,  167,  170,  177,  192,  195, 
270.  359,  390,  447,  475,  501,  517,  538, 
611,  632,  659 
cause  of  coma,  486 
of  convulsions,  486 
of  vomiting,  6oq 
Amyloid  metamorphosis  of  liver,  318 
Anal  fistula,  317 
Anemia,  140 

cause  of  headache,  32 

pernicious,  146,  150,  540,  549,  570,  574, 

739 
secondary,  151,  539 
Aneurysm,  165,  190,  292,  297.  290,  327,  337, 
340,  344,  345.  582 
abdominal,  172 
aortic,  89,  100,  142,  206 
called  rheumatism,  327 
cause  of  brachial  pain,  325 

of  lumbar  pain,  108 
of  si)ine,  1 18 
thoracic,  315,  341 
Angina  alxlominalis.  165,  i()0.  182 
cause  of  epigastric  pain.  153 
pectoris,  ib,  177.  1S2,  295,  J07.  308,  313, 
310.  343,  344 
cause  of  brachial  pain,  3:5 
functional,  243 
low,  168 
.\nginal  i)ain.  lour  occasions  tor.  344 

717 


748 


INDEX 


Anginoid  pain,  26 

Ankle,  s]>rained,  cause  of  pain  in  legs  and 

feet,  351 
Anorexia  nervosa,  436 
Aorta,  dynamic,  141,  143 

syphilitic  heart  and,  296 
Aortic  aneurysm,  86,  log,  142,  296 
insufficiency,  207 
regurgitation  cause  of  cough,  577 
stenosis  and  regurgitation,  694 
valves,  fibrous  endocarditis  of,  215 
Apoplexy,  389,  497,  510 
cause  of  coma,  487 

with  hemiplegia  cause  of  paralysis,  533 
Appendicitis,  89,  93,  loi,  131,  133,  136,  138, 
179,  192,  260,  262,  263,  267,  268,  356, 
419,  445,  613,  646 
acute,  64,  264 

cause  of  short  fever,  404 
of  vomiting,  609 
and  bronchitis,  128,  584 
cause  of  epigastric  pain,  155 
of  general  abdominal  pain,  129 
of  right  iliac  pain,  259 
chronic,  191,  622,  630,  640 
fear  of,  cause  of  right  iliac  pain,  259 
peptic  ulcer  and  gall-stones,  192 
Appendicular  colic,  270 
Appendix,  "  high,"  207,  209,  236 

cause    of    right    hypochondriac    pain, 
204 
Apprehension,  542 
Arm  and  shoulder,  neoplasm  of,  cause  of 

brachial  pain,  325 
Arms,  pain  in,  326 
Arsenical  poisoning,  558 
Arterial  spasm,  30 

Arteriosclerosis,    31,  32,  51,   181,  301,  353, 
540,  541,  600,  612 
cerebral,  521 
general,  521 
Arthritis,  66,  180,  332,  343,  379 
acute,  cause  of  short  fe\'er,  404 

of  hi]),  369 
atrophic,  334,  i,^.^-  ,^84 

cause  of  j^ain  in  legs  anfl  feet.  351 
gonorrheal,  06,  350,  392 
hypertrophic,  334,  352,  384 
cause  of  lumbar  pain,  <Si 

of  ]iain  in  legs  and  feet.  351 
spinal,  89 

radiations    from,    cause    of    axillary 
pain,  289 


Arthritis,  infectious,  381 
cause  of  long  fever,  403 

of  ]>ain  in  legs  and  feet,  351 
of  hip,  368 

of  left  sacro-iliac  joint,  107 
of  spine,  107 

cause  of  lumbar  pain,  81 
osteo-.     See  Osteo-arthritis. 
pneumococcus,  375 
rheumatic,  66,  365,  384 
sacro-iliac,  179 
of  shoulder-joint,  338 
various  types  of,  cause  of  brachial  pain, 

325 
Artificial  menopause,  302 

Ascending  colon,  cancer  of,  657 
Ascites,  315 
Astasia  abasia,  529 
Asthma,  bronchial,  316 

and  bronchitis,  595 

cause  of  cough,  577 
of  dyspnea,  687 
Ataxic  paraplegia  cause  of  paralysis,  533 
Atrophic  arthritis,  334,  353,  384 

cause  of  pain  in  legs  and  feet,  351 
Atrophy  of  liver,  acute  yellow,  727 
Attempted  miscarriage,  613 
Attention,  expectant,  206 
Atypical  forms  of  malaria,  641 
"  Auto-intoxication,"  301 
Axillary  abscess,  deep,  334,  484 

pain,  290 

B.-vcK,   acute   sprain   of^   cause   of   lumbar 
pain,  81 

strain,  96 
Backache,  "  functional,"  79,  87.  103 

"  kidney  group,"  86 

"  orthopedic  group,"  80,  86,  go.  91,  loi, 
118,  120  ^ 

"  postural,"  79 

"pressure  grouji,"  86,  108,  109,  118,  119 

sacro-iliac,  79 

"  uterine,"  79 
Bad  air  cause  of  headache,  2>3i 

hygiene,  132 
lialance,  defective,   cause  of  lumbar  pain, 

81 
Banti's  disease.  551 
Base  of  skull,  fracture  of,  54 
liasedow's  disease,  51 
"  Bed  fever,"  457 
Bile-ducts,  cancer  of.  cause  of  jaundice,  717 


INDEX 


749 


"  Biliousness,"  35 

cause  of  headache,  33 
Birth  palsy  cause  of  jjaralysis,  533 
Bismuth  poisoning,  subnitrate  of,  228 
Bladder  cancer,  278,  674,  676 

gall-.     See  Gall-bladder. 

stone  in,  279,  675,  676,  684 

tuberculosis  of,  280,  669,  670,  680 

tumor  of,  cause  of  hematuria,  666 
Blootl.     See  Hematuria,  Hemoptysis,  etc. 

cultures,  74 
Bones,  tuberculosis  of,  346 
Bowel,  cancer  of,  86,  170.     See  also  Colon. 

ulcer  of.  86 
Boys    of    fourteen    and    fifteen,    infections 

common  in,  445,  469 
Brachial  neuralgia,  336,  338 

neuritis,  338 
Brain,  concussion  of,  55 

softening,  77 

tumor,  55,  61,  70,  TS,  77-  4-'3.  40^>.  5io> 
517,  523,  528,  615,  640,  642,  644,  737 
cause  of  coma,  487 
of  headache,  33.  38,  46 

"  wet,"  77 
"  Brain-fag,"  525 
Brcur,  372 
lirewcr,  (1.  E.,  100 
Bright's  disease,  chronic,  254,  t,^j,,  625,  640, 

673.  676 
Broken  rib,  292 
lironchia!  asthma,  316 
lironchiectasis,  581,  588,  509 

inlluenzal  infection  of,  304 
Broncliitis,  304,  5S2.  ()03 

acute,  471 

cause  of  sliort  fe\'iT.  404 

and  appendicitis,  12S,  584 

and  asthma,  585 

and  emphysema,  700 

bronchopneumonia,    bronchiectasis,    and 
emphysema,  590 

causi-  of  cough,  577 

chronic.  218 

cause  of  dysi)nca,  ()cS7 
Hroin  ho|)ncum()nia,  51  5 

bronchiectasis,    emphysema,    and    bron- 
chitis, 500 

streptococcus,   587 
15ul)o,  2Sj 

"  Hurning  pain,"  223 

lUu'siiis.  subacromial.  ;^o.  ss.v  .vv^-  ,-i3''.  .vv*^ 
cause  of  brae  hial  jiain,  325 


Calculus.     See  Stone. 
Cancer,  97,  260,  269,  725 
of  bile-ducts  cause  of  jaundice,  717 
of  bladder,  278,  674,  686 
of  bowel,  86,  170 

cause  of  long  fever,  403 
of  colon,  196,  252,  255,  257.  281,  618,  657 
of  duodenum  cause  of  jaundice,  717 
of  gall-bladder  cause  of  jaundice,  717 
gastric,  86,   144  156,  159,   161,  163,  166, 
175,  184,  189,  194,  223,  252,  536,  548, 
614,  616,  636,  648,  651,  658 
cause  of  epigastric  [)ain.  155 
of  jaundice,  717 
of  vomiting,  609 
hepatic,  157,  196,  211,  229,  37c,  408,  550, 
720,  727 
cause  of  jaundice,  717 

of  right  h>qwchondriac  pain,  204 
intestinal,  147,  159,  277,  574 
of  liver.     See  Cancer,  hepatic. 
of  pancreas,  186,  224.  230,  726 

cause  of  jaundice,  717 
rectal  or  intestinal,  574 
of  rectum,  150 
recurrent  intestinal,  146 
of  sigmoid,  281,  283,  618 

cause  of  left  iliac  pain,  276 
of  spine  cause  of  lumbar  pain,  81 
of  splenic  llexure,  252,  255 
of  stomach.     See  Cancer,  f^uslric. 
of  uterus,  381 
Cardiac  cases,  sudden  death  in.  400 

dilatation,  acute,  40.  51.  297.  314.  704,  700 
disease,  40,  22h.  54(),    560.   ()05.   612,  700, 
710 
cause  of  dyspnea.  687 
of  vomiting.  600 
hy])ertrophy  and  dilatation,  40.  207 
insutlicicncv,  701 
Cardiorenai  disease,  630 
Caries  sii'ca,  334,  33S 
Catarrhal  jaundice,  210,  454,  626,  717,  719, 

721,  723,  724,  72S 
"  Cathartic  metliod."  3/2 
Ceral  rei^ion,  tut)tTculosis  of.  2()i 
Cellulitis,  336,  340 

infectious,  332 
Central  itni-uiuonia.  447 
Cerei)ral  abx  ess,  5  10 
arteriosi  lerosi>,  5^1 
con(  u^sion,  55 

cau^e  oi  he.i'l.ii  he,  3s 


75° 


INDEX 


Cerebral  hemorrhage,  70,  76 

softening,  77 
syphilis,  57 

tumor.     See  Tumor,  brain. 
cause  of  headache,  33,  38,  46 
Cerebrospinal  syphilis,  391 
Cervical  rib,  327,  336.  337,  340 
cause  of  brachial  pain,  325 
Charcot  joint,  383 

Charts  and  diagrams,  explanation  of,  22 
Chest,  malignant  disease  of,  312,  316 

wall,  malignant  disease  of,  320 
Childbirth  cause  of  lumbar  pain,  81 
Children's  fevers,  417 
Chills,  461 
causes  of,  461 
"  creeping,"  461 
*'  nervous,"  461 
occurring  in  typhoid  fever,  480 
Chlorosis,  160,  397,  544,  621,  732 
Cholangitis,  210 
Cholecystitis,  loi,  191 
acute,  219 

cause  of  right  hN-pochondriac  pain,  204 
typhoid,  210,  238 
Choledochus,  stone  in  ductus,  224,  232 
Cholelithiasis,  86,  113,  164.  165,  169,  170, 
174,  17s,  176,  182,  187,  192,  197,  198, 
206,  210,  235,  252,  265,  307,  483,  630, 
719,  722,  723,  724 
cause  of  chills.  460 
of  epigastric  pain,  155 
of  jaundice,  717 

of  right  hypochondriac  pain,  204 
with  perforations,  178 
Circumflex  paralysis,  334.  338 
Cirrhosis  of  liver,  145,  187,  196,  213,  225, 
232,  246.  318,  550,  612,  648,  725,  728 
cause  of  jaundice,  717 
of  long  fever,  403 
Claudication,  intermittent,  cause  of  pain  in 

legs  and  feet,  351 
Clubbed  fingers,  390 
Cobb,  Farrar,  loo 
Cocain  habit,  132 
"  Colds,  common,"  48 

cause  of  short  fc\XTS,  404 
Colic,  26,  515 

appendicular,  270 
lead-,  131 
renal,  144 
Colica  mucosa  cause  of  right  iliac  pain,  259 
Colitis,  chronic,  150 


Colitis,  mucous,  126,  131,  269 
perforative,  149 

tuberculous,  146 
Colon  bacillus  infection,  103 

cancer  of,   196,  252,  255,  257,   281,  283, 
618,  657 
Column,  spinal.     See  Spinal  column. 
Coma,  488 

causes  of,  488 
Comatose  or  convulsive  patients,  examina- 
tion of,  488 
"  Common  colds,"  48 

cause  of  short  fevers,  404 
Common  duct,  stone  in,  224,  232 

infections  cause  of  headache,  35 
Concomitant  nephritis,  59 
Concussion  of  brain,  55 
Congestion,  gastrohepatic,  due  to  cirrhosis 
or  cardiac  disease  cause  of  epigastric 
pain.  155 

hepatic,  195,  318 

cause  of  right  hypochondriac  pain,  204 
Constipation,  133,  152,  159,  161,  162,  166, 
170,  173,  175,  177,  195,  198,  280,  614, 
623,  624,  661 

cause  of  epigastric  pain,  155 
of  general  abdominal  pain,  129 
of  headache,  32 

(neurosis?),  623,  624 
Constitutional  headache,  48 
Constriction,  pain  with  a  sense  of,  26 
Contusion,  335 

Convalescence  from  pneumonia,  560 
Convulsions,  501 

causes  of,  488 
Convulsive  patients,  examination  of  coma- 
tose or,  488 
Costal  tuberculosis,  320 
Cough,  576 

causes  of,  576 

'■  heart,"  599 

mixture,  601 

varieties  of,  576 
Courvoisier's  law,  187 
Craig,  Charles  F.,  641 
"  Cramp,  writer's,"  524 
Crisis,  gastric,  128,  166,  (130,  642,  O51 

vascular,  31,  181,  387,  432,  510,  511,  521 
Croup,  708 
Cultures,  blood,  74 
Curschmann,  601 
Curvature,  spinal,  380 
C>'st,  h>'dati(l,  of  li\'er,  221,  230 


INDEX 


751 


Cyst,  ovarian,  267,  269,  272 
cause  of  left  iliac  pain,  276 

of  right  iliac  pain,  259 
ruptured,  266 
strangulated,  283 
with  twisted  pedicle,  263,  265 
renal.     See  Cystic  kidneys. 
Cystadenoma,  papillary,  of  kidney,  677 
Cystic  kidneys,  congenital,  86,  115,  221,  246, 

256 
Cystitis,  669,  675,  683 
cause  of  hematuria,  666 
chronic,  280 
gonorrheal,  280 
of  unknown  origin,  675 

Death,  sudden,  in  cardiac  cases,  496 
Debility,  101,  120,  158,  225,  227,  562,  698 
Defective   balance   cause   of   lumbar   pain, 

86 
Deforming  osteitis,  48 
Deformity,  round-shoulder,  342 
Degree  of  pain,  25 
Delirium,  salicylate,  364 

tremens,  660 
Dementia  paralytica,  67,  6q,  521,  525,  742 
cause  of  coma,  487 
of  paralysis,  533 
Dercum,  Dr.  C.  T.,  80 
Diabetes  mellitus,  51,  140,  362,  434,  502, 

517,  551,  553,  572,  600,  62£,  731 
Diagnoses,  causes  of  incorrect,  17 
Diagnosis,  vulnerability  of  all  differential,  19 
Diagrams  and  charts,  explanation  of,  22 
Diarrhea  cause  of  cijigastric  pain,  155 

of  general  abdominal  pain,  129 
Diet,  Lenhartz's,  Dr.  H.  F.  Hewes's  modifi- 
cation of.  253 
Dilatation,  acute  cardiac,  49,  51,  297,  314, 

704,  700 
Diseases  frefjuently  diagnosed   as  rheuma- 
tism, 329 

not  considered  in  this  book,  21 
Dislocation  of  humerus,  335 
Displacement  of  !i\'er.  221 
Dislomiasis.  31 7 
Disturbances  of  sensation.  20 
Diverticulitis,  284 
Dorsal  tabes,  132.  161,  3S7.  555 
with  gastric  crises,  O42.  651 
Dropsy,  40.  301 .  355 

j)!eura!.  314 
Drug  habits,  659 


Drug  poisoning,  732 

Ductus  choledochus,  stone  in,  224,  232 

Dunn,  Dr.  Charles  Hunter,  217 

Duodenal  ulcer,  131,  140,  159,  163,  166,  167, 

169,  176,  212,  234 
Duodenum,  cancer  of,  cause  of  jaundice,  717 
Dynamic  aorta,  141,  143 
Dysentery,  399 
Dysmenorrhea,  26 

cause  of  left  iliac  pain,  276 
of  right  iliac  pain,  250 
Dyspepsia,  177,  319 
Dyspnea,  686 

causes  of,  689 

inspiratory  and  expiratory,  707 
Dysuria,  423 

Eclampsia    (puerperal)    cause   of    convul- 
sions, 500 

Ectopic  gestation  cause  of  left  iliac  pain,  276 

Edema,  acute  pulmonary,  305 

Edingcr,  35 

Effusion,  dropsical,  301 
pericardial,  205,  314 
pleural,  299,  300,  306,  353,  439,  598,  654, 

739 
purulent,  318 
Embolism,  70 
Emotional  excitement,  its  relation  to  pain, 

^7 
Emphysema,  88,  300,  590,  700 

cause  of  cough,  577 
of  dyspnea,  687 
Empyema,  229,  318,  429,  482,  547,  581 

interlobar,  415,  503 

necessitatis.  320 

postpneumonic,  63,  415.  593,  594,  703 

tuberculous,  545,  701 
Endocardial  fever,  420 

infection,  465 
Endocarditis,  95,   180.  375,  469,   544.  564, 
695 

acute.  740 

fibrous,  of  mitral  and  aortic  valves,  215 

gonorrheal,  302 

mitral.  3()5 

ulcerative  for  malignant).  02,  430 
Endometritis,  hyperplastic,  608 
Endothelioma,  pleural,  738 
Enteritis.  (>4S 

cause  of  epigastric  pain.  155 
of  general  ahdoniinal  p.iin.  i  :S 

gastro-,  143,  040 


752 


INDEX 


Enteritis,  tuberculous,  256 

Enuresis,  683 

Epidemic  meningitis,  57,  441,  508 

poliomyelitis,  558 
Epididymitis,  tubercular,  115 
I-2piRastric  pain.  156 
Epilepsy,  501,  505.  517,  521,  524,  700 

cause  of  convulsions,  500 

Jacksonian.  392.  524 

nocturnal,  509 
Erysipelas  cause  of  short  fever,  404 
Erythematous  lesions,  73 
"  Essential  "  headache.  48 
Estivo-autumnal  malaria,  420.  456 
Evidences  of  pain,  24 
Evils  of  obesity,  resulting,  373 
Examination   of   comatose  and   convulsive 

patients,  488 
Excitement  cause  of  dyspnea,  687 

emotional,  and  its  relation  to  pain,  27 
Exertion  cause  of  dyspnea.  687 
Exhaustion,  477,  628 

nervous,  649 

postepileptic,  cause  of  coma,  487 
"  Expectant  attention,"  206 
P^xpiratory  and  inspiratory  dyspnea,  707 
Extra-uterine  pregnancy,  262 

cause  of  general  abdominal  pain,  129 
of  right  iliac  pain.  259 
Eye-strain  cause  of  headache,  ;};^,  42,  67 

Fatigue  cause  of  brachial  pain.  325 
of  headache,  32,  33,  525 
of  lumbar  pain.  80,  81 

poisons,  32 
Fatty  metamorjihosis  of  liver,  318 
"  Febricula."  138 
Fecal  impaction.  424 
FY'ct.  pain  in  legs  and,  352 
Femur,  sarcoma  of,  383 
Fc\-ers,  401 

'■  bed-."  457 

of  chiklren.  41  7 

endocardial.  420 

gall-stone,  40.S 

glandular,  452 

long.  401.  403 

non-infectious.  405 

short,  401,  405 

slow,  301 

urticarial,  457 
F'ibroid  tumor  of  uterus,  173.  263.  283 

uterine.  1 7 ,.  26; 


Fibrous   endocarditis   of   mitral   and   aortic 
valves,  215 

myocarditis,  chronic,  612,  705,  709 
Fingers,  clubbed,  390 
Fistula  in  ano,  317 
Fixation  abscess,  207 
Flat-foot,  366.  371,  379,  385,  388,  395 

cause  of  pain  in  legs  and  feet.  351 
Flatulence,  200.  244,  313,  319 

cause  of  axillary  pain,  289 
Flint,  Austin,  216 
Floating  kidney,  225,  273,  639 
Floyd,  Dr.  Cleaveland,  587.  600 
F'ood,  relation  of  pain  to  taking  of.  28 
Food-strain,  acute,  372 
Fracture  of  base  of  skull,  54 

of  humerus.  334.  335 
Fractured  pelvis,  366 

rib  cause  of  axillary  pain,  289 
Freud,  S.,  372 
Frontal  sinus,  disease  of,  cause  of  headache. 

42 
Functional  affection  of  spine,  108 

angina  pectoris,  243 

backache.  79,  §6,  103,  108,  118 

neurosis,  265 

G.ALL-BL.\DDER,  canccr  of,  cause  of    jaun- 
dice, 717 

disease,  157 

enlargement  of,  221 

gangrenous,  176 

infection,  131,  397 
Gall-stone  disease,  475,  663 

fever,  408 
Gall-stones,     See  Cholelithiasis. 
'■  Gastralgia.'"  164 
Cjastrectasis.  67 
Gastric  cancer.     See  Cancer,  gastric. 

crisis,  tabes  dorsalis  with,  128,  166,  630, 
642.  651 

flatulence.  200 

hef)atic    congestion    due    to    cirrhosis    or 
cardiac  disease  cause  of  epigastric  pain. 

155 
neurosis,  162,  189,  190,  257.  615.  622,  631, 
633,  640.  655.  661 
cause  of  ejiigaslric  pain,  155 
of  general  abdominal  pain,  129 
of  vomiting.  O09 
tumor.  115 

ulcer,   86.    157,    187,    191,   6i().   637,   64S. 
682,  737 


,lXAj\J,  ,vi^  , 


INDEX 


753 


Gastric  ulcer,  perforated,  89,  277 

Gastritis,  648 
alcoholic,  214 

cause  of  vomiting,  609 

phlegmonous,  472 
Gastro-enteritis,  143,  649 
Gastro-intestinal  disease,  psychic  causes  in, 
163 

tract,  infection  of,  653 
Gastroptosis,  635 
"  Gefasskrisen,"  30 

Genito-urinary  tuberculosis,  669,  675,  732 
Gestation,  ectopic,  cause  of  left  iliac  pain, 

276 
Glandular  fever,  432 

tuberculosis,  338,  471 
Glomerulonephritis,    chronic,    49,    60,    467, 

709 
Goiter,  51 
Gonorrhea,  139,  180,  260,  369,  376,  384,  387 

cause  of  long  fever,  403 
Gonorrheal  arthritis,  66,  350,  392 

cystitis,  280 

endocarditis,  302 
Gout,  365,  373,  376,  387,  529 

cause  of  pain  in  legs  and  feet,  351 
Graham,  Dr.,  192 
Graves'  disease  (hyperthyroidism),  49,  552, 

572,  629,  705,  709,  732 
Gregg,  Dr.  Donald,  332 
"  Grip,"  54,  91,  95,  138,  294,  403,  412,  443, 

465,  484,  506,  561,  653 
Gumma,  hepatic,  156 
Gummatous  tumor,  345 
Guthrie,  Dr.,  192 

Harit,  cocain,  132 
drug,  659 

"  Flabit  "  pain,  29,  85,  317 
Hagenbauch,  222 

Head,  Henry,  29,  248 
Headache,  32 

causes  of.  39 

constitutional,  48 

due  to  trauma,  44 

"  essential,"  48 

general  considerations  on,  32 

induratixe,  33,  35 

its  position  and  nature,  37 

■'  neiiralj^ic,"  71 

■■  iieurastlienic,"  48,  54,  67 

of  psychic  origin,  47,  73 

"  rlu'unialic,"  3^),  42 


Headache,  "  sick,"  50 
syphilitic,  43 
of  unknown  origin,  68 
uremic,  49 

vasomotor,  26,  37 
"  Heart  cough,"  599 

Heart,    dilated,    difference    between    peri- 
cardial effusion  and,  314 
disease,  40,  226,  546,  569,  605,  612,  709, 
710  '.^:-  U- 

congenital,  522 
hypertrophy  and  dilatation,  49,  297 
syphilitic,  and  aorta,  296 
weak,  305 
Heberden's  nodes,  390 
Hematogenous  infection  of  kidney,  86,  91, 

98,  678 
Hematoma,  335 
Hematuria,  667 

cause  unknown,  678,  682 
causes  and  types,  667 
Hemolysis,  367 

Hemolytic  jaundice,  chronic,  537 
Hemoptysis,  causes  of,  595 
Hemorrhage,  549 
cerebral,  70,  76 
Hemorrhagic  conditions,  317 
Hemorrhagica,  purpura,  317 
Hemothorax,  301 

Hepatic  abscess,  89,  230,  231,  318,  462,  475 
atrophy  (acute),  727 
cancer,  157,  196,  211,  229,  370,  408,  550, 
720,  727 
cause  of  jaundice,  717 
of  right  hypochondriac  pain,  204 
congestion,  195,  318 

cause  of  right  hypochondriac  pain,  204 
diseases,  421 
displacement,  221 
gumma,  syphilitic,  154 
infection,  473 

and  pulmonary  abscess,  462 
syjihilis.     See  Syphilis,  hepatic. 
IIei)atilis,  chronic  interstitial,  722 
Herpes  zoster,  86,  93,  360 

cause  of  lumbar  pain.  Si 
"  High"  appendix,  207,  200.  230 

cause  of  right  liypoc  hoiniriac  pain.  204 
Hip,  acute  arthritis  of,  3(k) 
infection  of,  368 
disease  (tuberc  ulous),  qU.  3()q 
infeilit)us  arihritis  of,  308 
Histor\-  of  iiijurx'  xmiciinu's  nuVIcadiiig,  339 


754 


INDEX 


Hodgkin's  disease,  318,  453,  471,  483 
Humerus,  dislocation  of,  335 

fracture  of,  334,  335 

osteomyelitis  of,  cause  of  brachial  pain, 

sarcoma  of,  338,  339 

septic  osteomyelitis  of,  334 

tuberculosis  of,  333,  336 
Hunger  cause  of  headache,  32,  ^;i 
Hydatid  cyst  of  liver,  221,  230 

infection,  213 
Hydronephrosis,  86,  115,  221 

cause  of  right  hypochondriac  pain,  204 
Hydrothorax,  218,  703 
Hygiene,  bad,  132 
Hyperchlorhydria,  159,  165,  167,  170,  251, 

257 
cause  of  epigastric  pain,  155 
Hyperemia,  \ascular,  26 
Hypernephroma,  255,  670,  681 

metastatic,  344 
Hyperperistalsis.  26 
Hyperplastic  endometritis,  698 
Hypertension,  nephritic,  31 
Hyperthyroidism.     See  Graves'  disease. 
Hypertrophic  arthritis,  334,  352,  384 
cause  of  lumbar  pain,  81 
of  pain  in  legs  and  feet,  351 
spinal  arthritis,  89 

radiation  from,  cause  of  axillary  pain, 
289 
spondylitis,  80 
Hypertrophy  and  dilatation  of  heart,  49, 

297 
Hypochlorhydria,  167,  251,  617,  620 
Iiy|)ochondriac  pain,  left,  241 

right,  205 
Hysteria,  57,  385,  464,  493,  494,  502,  505, 
604,  659,  737 
cause  of  con\ulsions,  500 
and  epileps},'.  505 
minor,  236 
Hysteric  affection  of  spine,  108 
polypnea.  600 
suggestibility.  507 

Icterus  neonatorum  cause  of  jaundice,  717 
Iliac  pain,  left,  277 

rigiil.  260 
Impaction,  fecal,  423 
Incarcerated  uterus,  126 
Incomplete  miscarriage,  645 
Indigestion,  443 


Indigestion  cause  of  epigastric  pain,  155 

of  headache,  32,  ;^;^ 
Indurative  headache,  ;^^,  35 
Infantile  paralysis,  391 

spasm  cause  of  convulsions,  500 
Infarct,  renal,  86 
Infection,  acute,  of  hip,  368 
cause  of  headache,  35 
colon  bacillus,  103 
endocardial,  465 
gall-bladder,  397 
of  gastro-intestinal  tract,  653 
general,  109,  118,  207 
hydatid,  213 

influenzal,  of  small  bronchiectasis,  304 
of  liver,  473 
localized,  451 
perirenal,  cause  of  right  hypochondriac 

pain.  204 
pharyngeal,  449 
pneumococcus,  446 

general,  435 
of  puberty,  445,  469 
pyogenic,  364 
general,  363 
renal,  86,  98,  99,  loi,  250,  406,  416,  678 

cause  of  right  hyj^ochondriac  pain,  204 
'■  scattering,"  cause  of  long  fever,  403 
staphylococcus,  65 
terminal,  353 
unknown,  54,  95,  293,  443 
urinary,  104,  564 
Infectious  arthritis,  381 

cause  of  long  fe\-er.  403 

of  pain  in  legs  and  feet,  351 
of  hip,  368 

of  sacro-iliac  joint,  107 
of  spine,  107 

cause  of  lumbar  pain,  81 
cellulitis,  332 

disease  cause  of  dyspnea,  687 
of  lumbar  pain,  81,  85 
of  pain  in  legs  and  feet,  351 
onset,  cause  of  headache,  ;i,Ti.  35 
of  vomiting,  609 
endocarditis,  695 
osteo-arthrilis,  acute,  118 
p<)l>-arthritis,  acute,  328 
spondylitis,   107,   110 
thrombosis,  ^^2 
Inflammation,  ])ain  clue  to,  328 
Influenza, 54, 91, 03,  13S.  294,  401,  412, 443, 
465,  484,  50O,  5O1,  5O8,  653 


INDEX 


755 


Influenza  cause  of  cough,  577 

of  long  fever,  403 

of  short  fever,  404 
Influenzal  infection  of  small  bronchiectases, 

304 
Injury,   history  of,   sometimes  misleading, 

339 
Insolation  cause  of  headache,  35 
Inspiratory  and  expiratory  dyspnea,  717 
Insufficiency,  aortic,  297 

myocardial,  61,  701,  710 
Intensity  of  jaundice,  719 
Intercostal  neuralgia,  319 

cause  of  axillary  pain,  289 
Interlobar  empyema,  415,  593 
Intermittent  claudication  cause  of  pain  in 

legs  and  feet,  351 
Interi)retation  of  nervousness,  730 

sym|)toms  and  their,  29 
Interstitial  hepatitis,  chronic,  722 

nephritis,  chronic,  511,  513,  646,  709,  710. 
741 
Intestinal  cancer,  147,  159,  277 
recurrent,  146 
obstruction,  51,   151,   152,   161,   198,   199 
cause  of  epigastric  pain,  155 
of  general  abdominal  pain,  1 29 
of  vomiting,  609 
chronic,  135,  166,  188.  658,  661 
stricture,  174 
Intrathoracic  tumor,  336 
Irritation,  pleural,  583 
Ischiorectal  abscess,  368,  400,  481 

Jacksonian  epilei)sy.  392,  524 
Janeway,  Ur.  E.  (i.,  603 
Jaundice,  715 

catarrhal,  210,  454,  626,   717,   719,   721, 

7-,v  7'4>  7-^ 

chronic  hemoljlic.  537 

intensity  of,  710 

s\mi)t()ms  associated  with,  716 

t\pcs  and  causes  of,  715 
Johns  Iloijkins  Hospital  report,  480 
Joinl,  ("harcot,  3S3 

infection  of  left  sacro-iliai ,  107 
of  shoulder,  338 
Joints,  sypliilitic  disease  of,  3()5 

KiDNKV  abscess,   1 1  i 

(ongenital  c\-slic,  Sf),   115,  221,  240,  25(1 
floating,  225,  273,  ()3() 
group  of  l)a(  kaches,  SO 


Kidney,  hematogenous  infections  of,  86,  678 
neoplasm,   86,    209,    221,    254,    256,    279, 

671,  678,  679,  683,  684 
papillary  cystadenoma  of,  677 
pus  in,  310 

tuberculous,  310 
stone  in.     See  Nephrolithiasis. 
"  surgical,"  112 

tuberculous,  59,  86,  112,  209,  221,   243, 
254,    256,    272,    279,   669,   670,    672, 
676,  677,  683 
cause  of  hematuria,  666 
tumor.     See  Renal  tumor. 
Knee,  septic,  383 

sprained,  cause  of  pain  in  legs  and  feet, 
351 

Laryngitis,  acute,  706 

Lead  colic,  131 

Lead-poisoning,  59,  86,  109,  132,  140,  144, 
151,  157,  160,  166,  169,  174,  175,  177, 
242,  257,  295,  391,  426,  517,  527,  554, 

557-  571 

cause  of  e|)igastric  pain,  155 
of  general  abdominal  pain,  129 
Left  hypochondriac  pain,  241 

iliac  pain,  277 
Leg  bones,  sarcoma  of,  cause  of  pain  in  legs 

and  feet,  351 
Legs  and  feet,  pain  in,  352 
Lenhartz's  diet.  Dr.  H.  F.  Hewes'  modifica- 
tion of,  253 
Leukemia,  73,  247,  252,  255,  282,  318,  408. 
453.  470.  672 

cause  of  long  fever,  403 

lymjihoid,  144 

myeloid,  247,  555 
Leukocytosis,  468 
Lipoma,  387 
"  Lithemia."  35 
Lithiasis.     See  Slo)U'. 
Liver  abscess,  89,  230,  231,  318,  4()2,  475 

acute  yellow  atrophy  of,  727 

amyloid  metamori)iiosis,  318 

cancer  of.    See  Liver,  iiuilii^nant  diseiise  of. 

cirrhosis  of.  145,  1S7,   106,  213,  22-;.  2^,2. 
24I),  31S,  550,  ()i2.  048.  725.  72S 

congestion  of,  195 

displaienient  of,  221 

enlargement  of,  3  18 

fatt\'  metamorphosis.  318 

hydatid  cyst  of.  221.  230 

infection  of,  473 


756 


INDEX 


Liver,  malignant  disease  of,  157,  196,  211, 
229,  370,  408,  550,  720,  727 
passive  congestion  of,  195,  318 
syphilis  of.     See  Syphilis,  hepatic. 
"  torpidity  of,"  35 
tumors  of,  229 
Lobar  pneumonia,  314,  415 
"  Localized  "  infections,  451 
"  Long  fevers,"  401,  403 
Lord,  F.  T.,  596 
Lovett  and  Reynolds,  80 
Lumbago,    37,    80,    86,    90,    96,  102,  108, 
no,  113,  114,  119,  296 
cause  of  lumbar  pain,  81 
and  sciatica,  396 
Lumbar  neuralgia,  86 
neuritis,  86 
pain,  79 

causes  of,  86 
due  to  aneurysm,  108 
to  fatigue,  80 
to  functional  causes,  108 
to  infectious  disease,  85 
to  osteo-arthritis,  108,  362 
to  parturition,  85 
infectious  group,  91 

orthopedic   group.     See   Backache,   or- 
thopedic group. 
postoperative,  85,  87 
pressure  group,  86,  108,  109,  118,  119 
psychoneurotic,  84 
renal  group,  90 
Lung,  abscess  of,  218,  462,  566,  577,  589, 

594 

malignant  disease  of,  426,  583 

syphilitic  disease  of,  602 
Lymphangitis,  332 

cause  of  short  fever,  404 
Lymphoid  leukemia,  144 
Lymphoma,  malignant,  346 

Malaria,  40,  48,  54-56,  60,  66,  74,  75,  77, 
190,  407,  412,  427,  463,  468,  472,  479, 
634,  644,  646,  671 
,    atypical  forms,  641 

cause  of  general  abdominal  jjain,  1 29 
estivo-autumnal,  420,  456 
in  New  England  cause  of  chills,  460 
tertian,  121, 148,294,639,642,722 
Malaria!  poisoning,  chronic,  537 
Malignant  disease,  42,  59,  340,  342 
of  chest- wall,  312,  316,  320 
of  kidney,  209,  254,  279,  671 


Malignant  disease  of   liver,  157,  196,  211, 
229,  370,  408,  550,  720,  727 
of  lung,  426,  583 
of  mediastinal  glands,  426,  583 
of  pleura,  426,  583 
growth  in  or  near  spinal  column,  91 
lymphoma,  346 
McGuire,  Dr.  Stewart,  637 
McKenzie,  James,  29 
Measles,  442 

Mediastinal  glands,  malignant  disease  of, 
329,  426,  583 
tumor,  328,  347 
cause  of  brachial  pain,  325 
Melancholia,  193 
Meningismus,  310,  480 

complicating  typhoid,  122 
Meningitis,  55,  69,  72,  77,  121,  359,  391,  431, 
435,  445,  480,  482,  502,  515,  517,  523, 
524,  642,  737 
acute,  291 
cause  of  coma,  487 
of  convulsions,  500 
of  headache,  ^^ 
of  long  fever,  403 
epidemic,  57,  441,  508 
tuberculous,  53,  56,  57,  75,  158,  643 
Menopause,  734 
artificial,  302 
Menstruation  cause  of  headache,  33,  35 

vicarious,  317 
Mesenteric  adenitis,  357 

gland,  tuberculosis  of,  357,  427 
tabes,  128,  264,  358,  369 
Metamorphosis,  amyloid,  of  ]i\cr,  318 

fatty,  of  liver,  318 
Metastatic  hypernephroma,  344 
Metatarsalgia,  Morton's,  cause  of  pain  in 

legs  and  feet,  351 
Methemoglobinemia,  39 
Migraine,  38,  46,  61 
Miliary  tuberculosis,  56,  74,  239,  304,  454, 

600,  692 
Miscarriage,  attempted,  613 

incomplete,  645 
Mitral  and  aortic  valves,  fibrous  endocar- 
ditis of,  215 
disease,  493 

cause  of  cough,  577 
endocarditis,  365 
stenosis,  51,  656,  695,  711 
Morphin,  662 
Morphinism,  q8,  538,  632 


/    iCA^yi^Jk.  V    ir  I 


INDEX 


757 


Morton's  metatarsalgia  cause  of  pain  in  legs 

and  feet,  351 
Motion,  its  relation  to  pain,  28 
Mucous  colitis,  128,  131,  259,  269 
Multilocular  ovarian  cyst,  282 
Muscular  lesions,  343 

pains,  328 

strain,  1 19 
Myelitis,  558 

acute,  391 
Myeloid  leukemia,  247,  555 
Myocardial  insufficiency,  61,  710 

weakness,  cause  of  cough,  577 
Myocarditis,  306,  695 

chronic  fibrous,  612,  705 

fibrous,  709 
Myositis,  chronic,  36 

septic,  332 
Myxedema,  40,  543,  573 

Neoplasm,  109,  335 

of  arm  and  shoulder  cause  of  brachial 

pain,  325 
of  kidney,  86,  671,  678 
mediastinal,  329 
pelvic,  380 

retroperitoneal,  cause  of  right  hypochon- 
driac pain,  204 
spinal,  86,  118 
Nephritis,  51,  61,   158,  200,  434,  477,  517, 
541,  642,  669.  675,  732 
acute,  709 
cause  of  headache,  j,^,  46 

of  hematuria,  666 
chronic,  254,  353,  625,  640,  673,  676 
cause  of  dysjinca,  687 

of  hematuria.  ()66 
glomerulo-,  49,  60,  467.  709 
interstitial,  511,  513,  646,  700,  710,  741 
suppurative,  735 
Nephrolithiasis,  58,   50,   86,   111,    119,  208, 
253,  272,  270,  355,  630,  642,  678,  681 
cause  of  hematuria,  666 
of  himbar  i)ain,  81 
of  right  hyiKK'liondriac  pain,  204 
psoas  spasm  due  to.  355 
"  N(,'r\-ous  chills."  461 
Nervous  exhaustion,  649 
Ner\()usncss,  41  j.  7^0 
cause  of  cliills.  4O0 
inl(T|)relation  of.  7 -so 
Neuralgia,  (xj.  ^:i.  330,  331 
hrai  hial,  330.   ;:;S 


Neuralgia  cause  of  brachial  pain,  325 
intercostal,  319 

cause  of  axillary  pain,  289 
lumbar,  86 

trigeminal,  cause  of  headache,  33,  35 
"  Neuralgic  "  headache,  71 

pain,  26 
Neurasthenia,  114,  526,  619 
Neurasthenic  affection  of  spine,  108 

headache,  48,  54,  67 
Neuritis,  94,  98,  105,  198,  382 
alcoholic,  373,  555,  557 

cause  of  pain  in  legs  and  feet,  351 
brachial,  338 
cause  of  paralysis,  533 
lumbar,  86 
peripheral,  537,  540 
saturnine,  555 
with  herpes  zoster,  360 
Neurosis,  128,  134,  139,  152,  159,  162,  177, 
209,  248,  271,  312,  635,  662 
cause  of  epigastric  pain,  155 
and  constipation,  623,  624 
functional,  265 
of  spine,  118 
gastric,  162,  189,  190,  257,  615,  622,  631, 
633,  640,  655,  661 
cause  of  epigastric  pain,  155 
of  general  abdominal  jiain,  129 
of  vomiting,  600 
occupation,  cause  of  brachial  pain,  325 
^  postoperative,  136 

traumatic,  324,  335,  631,  738 
New-growth  of  kidney,   221,  256,  679,  683, 
684 
pelvic,  362 

renal.     See  Xn^'-iiroii'lh  of  kidney. 
New-growths  cause  of  lumbar  pain.  108 
Nocturnal  epilepsy.  500 

Orksity.  543 

ri'sulting  e\'ils  of.  373 
Obstruction,    chronic    intestinal,    135.    166. 
188,  ()5S.  661 
intestinal,  51.  151,  152,  lOi.  loS.  100 
lausc  of  c])igastrii-  jjaiii.  155 
of  gi'ncral  al)d()minal  jxnn.   1  jo 
Occupation.  clTecl  of.  its  relation  to  \):un.  27 

neurosis  tausc  of  l)racliial  ])ain,  3J5 
Opium-poisoning.  :jS 
Onliitis.  SN'philitic.  1  72 
Or(hoi)cdic  group  of  baikaclics.  So.  So.  no. 

91  ,    101  .    I  1  S.    1 20 


758 


INDEX 


Osier  on  "  Urticarial  Lesions,"  448 
Osteitis  deformans,  48 

tuberculous,  384 
Osteo-arthritis,  120,  381 
acute,  108 

infectious,  118 
cause  of  lumbar  pain,  108 
spinal,  86,  96,  114,  362 
Osteomyelitis,  65,  66 
cause  of  pain  in  legs  and  feet,  351 
of  humerus  cause  of  brachial  pain,  325 
septic,  334,  338-34O,  383 
of  humerus,  334 
of  rib,  320 
tuberculous,  333,  335,  340,  383 
of  rib,  320 
Otitis  media,  291,  451,  468,  46Q,  514 

cause  of  headache,  35 
Ovarian  cyst,  267,  269,  282 
ruptured,  266 
strangulated,  283 

with  twisted  pedicle,  263,  265,  282 
cause  of  left  iliac  pain,  276 
of  right  iliac  pain,  259 
tumor,  260 
Overwork,  734 
Oxalic  acid  poisoning,  647 
Oxaluria,  renal  irritation  from,  680 
cause  of  hematuria,  666 

Facet's  disease,  48 
Pain,  24 

abdominal,  26 

anginal,  four  occasions  for,  344 

anginoid,  26 

in  arms,  326 

axillary,  290 

"  burning,"  223 

causes  of  general  abdominal,  129 

darting,  26 

degree  of,  25 

due  to  inflammation,  328 

epigastric,  156 

evidences  of,  24 

functional  lumbar,  108 

general  abdominal,  128 
considerations  on,  24 
on  diagnosis  of,  286 

habit,  29,  85,  317 

in  left  hypochondrium,  241 

in  legs  and  feet,  352 

left  iliac,  281 

lumbar,  79 


Pain,  muscular,  328 
nerve,  328 
neuralgic,  26 
radiations  of,  30 

its  relation  to  effect  of  emotional  excite- 
ment, 27 
of  motion,  28 
of  occupation,  27 
of  season  and  weather,  28 
to  poison  of  body,  27 
to  taking  of  food,  28 
to  time  of  day,  27 
relief  of,  28 

rhythmically  recurring,  26 
right  hypochondriac,  205 

iliac,  260 
shooting,  26 

theories  regarding  its  production,  29 
thoracic,  26 
throbbing,  26 
types  of,  26 

with  a  sense  of  constriction,  26 
Pal,  J.,  29,  508 
Pancreas,  cancer  of,  186,  224,  230,  726 

cause  of  jaundice,  717 
Pancreatitis,  acute,  177 
cause  of  epigastric  pain,  155 
chronic,  186 
Papillary  cystadenoma  of  kidney,  677 
Papilloma,  676 

Paralysis,  circumflex,  334,  338 
general,  67,  69.  516,  521,  525,  742 
infantile,  391 
Paranephric  abscess,  86 
Paraplegia,  ataxic,  cause  of  paralysis,  533 
Paratyphoid,  457 

Parkinson's  disease  cause  of  paralysis,  533 
Paroxysmal  tachycardia,  61,  62 
Parturition,  123,  528 

cause  of  lumbar  pain,  85 
Passive  congestion  of  liver,  195,  318 
Paul,  W.  E.,  and  G.  L.  Walton.  32 
Pelvic  adhesions  cause  of  left  iliac  pain,  259 
of  right  iliac  pain,  204 
new-growth,  362,  380 
peritonitis.  173 
thrombosis,  367 
Pelvis,  fractured,  366 

Peptic  ulcer,  170.  174.  175,  182,  185,  190, 
192, 194, 198,  200,  223,  228,  246,  252, 
61 7,  620,  622,  630 
cause  of  ej^igastric  |)ain,  155 
of  vomiting,  609 


INDEX 


759 


Peptic  ulcer,  perforated,  89,  177,  277 
Perforative  colitis,  149 

peritonitis,  135,  144,  151,  193,  663 
Pericardial  effusion,  205,  314 

and  dilated  heart,  difference  between, 

314 
Pericarditis,  177,  113,  313,  695 
acute,  179 

adhesive,  51,  216,  705,  709 
cause  of  epigastric  pain,  155 
Pericecal  tuberculosis,  146,  233,  258,  261, 

426 
Perinephric  abscess,  87,  91,  318,  411 

cause  of  lumbar  pain,  81 
Periosteal  lesions,  343 
Periostitis,  338 

syphilitic,  41,  397,  398 
cause  of  headache,  ^^ 
of  pain  in  legs  and  feet,  351 
Peripheral  neuritis,  537,  540 

thrombosis,  367 
Perirectal  abscess,  411 
Perirenal    infection    cause    of   right   hypo- 
chondriac pain,  204 
Peristalsis  (visible),  308 
Peritonitis,  loi,  174,  177,  646,  650 
acute  perforative,  663 
general,  149,  151 

cause  of  general  abdominal  pain,  129 
pelvic,  173 

perforative,  135,  144,  151,  193 
tuberculous,  134,  142,  156,  158,  172,  174, 
188,  197,  247,  315,  419,  427,  456,  480, 
551,  564,  569 
cause  of  general  abdominal  pain,  129 
Pernicious  anemia,  146.  150,  540,  549,  570, 

574,  739 
Pertussis,  58 2 
"  Petit  mal,"  529 
Pharyngeal  infection,  449 
Pharyngitis,  acute,  cause  of  short  fever,  404 

cause  of  cough,  577 
Phlebitis,  340 

cause  of  ])ain  in  legs  and  feet,  351 
Phlegmonous  gastritis,  472 
Phthisis,  133.  217,  229,  298,  302,  304,  316, 
317,  341.  409,  413,  428,  463,  470,  471, 
567,  581,  586,  589,  593,  597,  599,  604, 
650,  074,  701,  732,  733 
cause  of  cliills,  460 
of  cough,  577 
of  (lys[)nc'a,  087 
pneumonic,  593 


Piles,  539 

Plastic  pleurisy,  chronic,  559 

Pleura,  endothelioma  of,  738 

malignant  disease  of,  426,  583 
Pleural  adhesions,  185,  303 
dropsy,  314 

effusion,  299,  300,  301,  306,  353,  439,  598, 
654,  703,  739 
purulent,  318 
irritation,  583 
thickening,  64 
chronic,  244 
Pleurisy,  88,  109,  123,  180,  206,  251,  252, 
255,  293,  294,  311,  313,  317,  370,  445, 
482,  546,  585,  586,  589 
cause  of  axillary  pain,  289 

of  cough,  577 
chronic  plastic,  317,  559 
double,  473 
tuberculous,  424,  475 
Pleurodynia,  293,  319,  323 
Pleuropericardial  adhesions,  185 
Plumbism.     See  Lead- poisoning. 
Pneumococcus  arthritis,  375 
infection,  446 
general,  435 
Pneumonia,  85,  88,  100,  121,  180,  206,  251, 
288,  292,  294,  299,  304,  306,  375,  399, 
407,  429,  431,  435,  441,  442,  444,  447, 
475,  479,  484,  538,  548,  585,  591,  594, 
634,  642,  652 
cause  of  axillary  pain,  289 
of  chills,  460 
of  cough.  577 
of  dyspnea,  687 
of  short  fever,  404 
central,  447 

convalescence  from,  560 
lobar,  314.  415 
traumatic,  596 
unresolved,  64 
diagnosis  made  at  the  Massachusetts 
(icncral  Hospital.  437 
Pneumothorax,  tubercular,  87,  298 
Poisoning,  arsenical,  558 
chronic  malarial.  537 
drug.  732 

lead-.     Sec   Lrad-f>oisoii!iii^. 
o[jiuni-.  2 28 
oxalic-  add.  047 

"  ptomain."  301,  443,  631,  ()^_^ 
sodium  phosphate,  537 
subnitratc  of  hismutli,  228 


760 


INDEX 


Poisoning,  tea-,  734 
Poisons  of  fatigue,  32 
Poliomyelitis,  416 

cause  of  paralysis,  533 
of  short  fever,  404 

epidemic,  558 
Polyarthritis,  acute  infectious,  328 
Polycythemia,  40 
Polypnea,  hysteric,  690 
Position  of  body,  relation  of  pain  to,  27 

and  nature  of  headache,  37 
Postepileptic  exhaustion  cause  of  coma,  487 
Postoperative  lumbar  pain,  81,  85 

neurosis,  136 

shock  cause  of  vomiting,  609 
Postpneumonic  empyema,  63,  415,  593,  594, 

703 
Postural  group  of  backaches,  79 
Pott's  disease,  86,  97,  98,  106,  108,  109,  347, 

358 
Pregnancy,  122,  260,  262,  269,  544,  613, 621 

extra-uterine,  262 

cause  of  general  abdominal  pain,  129 
of  right  iliac  pain,  259 

toxemia  of,  cause  of  vomiting,  609 

vomiting  of,  654 
Presenting  symptom,  17 
Pressure  group  of  backaches,  86,  108,  109, 

118,  119 
Prolapsed  uterus,  122 
Pseudoleukemia,  282 
Psoas  spasm  due  to  nephrolithiasis,  355 

tear,  357 
Psychic  cause  of  headache,  47,  73 

causes  in  gastro-intestinal  disease,  163 

origin,  headache  of,  47,  73 
Psycho-analysis,  372 

Psychoneurosis,  118,  132,  136,  179,  226,371, 
381,  538,  562 

cause  of  headache,  t,^^ 
of  right  iliac  pain,  259 
Psychoneurotic  lumbar  pain,  84 
"  Ptomain  poisoning,"  301,  443,  631,  653 
Puberty,  infection  of,  445,  469 
Pulmonary  abscess,  218,  462,  566,  579,  589, 

594 

disease,  700 

edema,  acute,  306 

tuberculosis.     See  Phthisis. 
Pupillary  changes,  67 
Purpura  hemorrhagica,  317 
Pus-kidney,  310 
Pus-tube,  563 


Pus-tube  cause  of  left  iliac  pain,  276 

of  right  iliac  pain,  259 
Pyelitis,  100 
Pyelonephritis,  474 
Pyloric  adhesions,  174 

cause  of  epigastric  pain,  155 
stenosis,  637 
Pyogenic  infection,  364 
general,  363 
sepsis  cause  of  chills,  460 
Pyonephrosis,  86,  221,  678 
cause  of  right  hypochondriac  pain,  204 
with  stone,  244 
Pyosalpinx,  260,  268 

Radiations  of  pain,  30 
Rectal  cancer,  150,  584 

Recurrent  intestinal  cancer,  146 
Recurring  pain,  rhythmic,  26 
Regurgitation,  aortic,  cause  of  cough,  577 
stenosis  and,  694 
mitral  stenosis  and,  695,  711 
tricuspid,  504 
Relief  of  pain,  28 
Renal  abscesses,  iii 
colic,  144 

cyst,  86,  115,  221,  246,  256 
disease,  118,  120,  196,  216,  223,  306,  434 
group  of  lesions,  109 

lumbar  pain,  90 
infarct,  86 

infection,  98,  99,  loi,  250,  406,  416 
cause  of  right  hypochondriac  pain,  204 
hematogenous,  86,  91,  98,  678 
irritation  from  oxaluria,  680 
lesions,  108,  120,  357 
neoplasm.     See  Neoplasm  of  kidney. 
new-growth.      See  New-growth  of  kidtiey. 
stasis,  51 
stone.     See  Nephrolithiasis. 

cause  of  lumbar  pain,  81 
suppuration  cause  of  lumbar  pain,  81 
tuberculosis.    See  Kidney,  tuberculosis  of. 
tumor,  272,  675 

cause  of  hematuria-,  666 
of  lumbar  pain,  81 
Retroperitoneal  glands,  tumors  of,  196 
neoplasms  cause  of  right  hypochondriac 

pain,  204 
sarcoma,  114 
tumor,  221 
cause  of  lumbar  pain,  81 
Retroverted  uterus,  122 


INDEX 


761 


Reynolds,  E.,  80 

Rheumatic  arthritis,  66,  365,  384 

"  Rheumatic  headache,"  36,  42 

Rheumatism,  66,  206,  328,  352,  364,  374 

aneurysm  called,  327 

diseases  frequently  diagnosed  as,  329 

sciatic,  362 
Rhythmic  recurring  pain,  26 
Rib,  broken,  289,  292 

cervical,  327,  336,  337,  340 
cause  of  brachial  pain,  325 

septic  osteomyelitis  of,  320 

tuberculous  osteomyelitis  of,  320 
Rickets,  48,  406,  515 
Right  hypochondriac  pain,  205 
.    iliac  pain,  260 
Rose  spots,  542 

Round-shoulder  deformity,  342 
"  Rum-fits,"  502,  511 
Ruptured  ovarian  cyst,  264 

Sacro-iliac  arthritis,  179 

backache,  79 

disease,  86,  90.  96,  102,  108,  120,  381 
cause  of  lumbar  pain,  81 

joint,  infectious  arthritis  of  left,  107 
lesion,  362 

lesions  cause  of  right  hjpochondriac  pain, 
204 

strain,  96,  07,  395 
Salicylate,  delirium  from,  364 
Salpingitis  cause  of  short  fever,    404 

tuberculous,  655 
Sarcoma,  109 

of  femur,  383 

of  humerus,  338,  339 

of  leg  bones  cause  of  pain  in  legs  and  feet, 

retro|Deritoneal,   114 

of  testis  with  metastases,  171 

Saturnine  neurilis.  :;()^ 

"  Scattering  "  infoi  lions  cause  of  long  fevers, 

403 
Schmidt.  Rudolf,  31,  86 
"  Sciatic  rhc'uniatisin,"  ^Oo 
Sciatica,  359,  3()o.  3()0 

cause  of  pain  in  U'gs  and  feet,  351 

primary,  3S1 
Sclerosis,  lateral,  (ause  of  paralysis,  533 
Sea-sickness  cause  of  vomiting,  600 
Season  and  weather,  their  relation  to  pain,  28 
Secondary  anemia,  151,  530 
Sensation,  disturban'  es  of,  2() 


Sepsis,  48,  91,  366,  394,  402,  427,  429,  437, 
439,  445-  646 
cause  of  jaundice,  7 1 7 

of  long  fever,  403 
pyogenic,  cause  of  chills,  460 
staphylococcus,  565 
streptococcus,  449 
with  thrombi,  308 
Septic  infection.     See  Sepsis. 
knee,  383 
myositis,  332 

osteomyelitis,  334,  338,  339,  340,  383 
of  humerus,  334 
of  rib,  320 
thrombosis,  410 
Septicemia.     See  Sepsis. 
Serous  pleurisy,  301,  703 
"  Shingles,"  86 

cause  of  lumbar  pain,  81 
"  Shock,"  postoperative,  cause  of  vomiting, 

609 
Shooting  pain,  26 
Short  fevers,  403,  405 
Shoulder  deformity,  round-,  342 
Shoulder-joint,  arthritis  of,  338 
"  Sick  headache,"  50 
Sigmoid,  cancer  of,  281,  283,  618 

cause  of  left  iliac  pain.  276 
Sinusitis,  42,  55,  69,  71 
cause  of  headache,  ;^,i, 
I  of  short  fever,  404 

j  Skull,  fracture  of  base  of,  54 
j  "Slow  fever,"  301 

Softening,  cerebral,  77 
j  Spasm,  arterial,  30 

infantile,  cause  of  convulsions,  ^cx) 
psoas,  due  to  nephrolithiasis,  355 
Spinal  aneurysm,  118 
I      arthritis,  hypertrophic.  89 

radiations    from,    cause    of    axillary 
pain,  280 
column,  disease  of.  320 

malignant  growth  in  or  near,  8(),  87,  91 , 
I  iS 
(■ur\'ature,  ^So 
disease,  102 

osteo-arthritis,  8(),  oO,  114 
tuberculosis,  S().  01,    loO-ioS.    115.   117, 
I  20.  i3(),  1S4.  342,  5()S 
cause  of  general  abdominal  |),un.  120 
of  lumbar  i)ain.  Si 
Spine.  fuiK  tional  affection  of.   loS 
neurosis  of,  i  iS 


762 


INDEX 


Spine,  infectious  arthritis  of,  107 
cause  of  lumbar  pain,  81 

osteo-arthritis  of  lumbar,  362 
Spleen,  obsolete  tuberculosis  of,  49 

tumor  of,  248 
Splenic  enlargement  with  anemia,  556 

flexure,  cancer  of,  252,  255 
Spondylitis,  293 

acute,  118 

hypertrophic,  80 

infectious,  icy,  110 

typhoidal,  115 
Sprain,  acute,  of  back,  cause  of  lumbar  pain, 

81 
Sprained  ankle  cause  of  pain  in  legs  and 
feet,  351 

knee  cause  of  pain  in  legs  and  feet,  351 
Staphylococcus  infection,  65 

sepsis,  565 
Starvation,  320 
Stasis,  315,  605 

renal,  51 
Stenosis,  aortic,  694 

mitral,  51,  654,  695,  711 

pyloric,  637 
Stiff  neck,  37 

Stokes-Adams'  disease,  435,  492,  518,  520 
Stomach,  cancer  of.     See  Cancer,  gastric. 

tumor.     See  Gastric  tumor. 

ulcer  of.     See  Gastric  ulcer. 
Stone  in  bladder,  279.  675,  676,  684 

in  common  duct,  224,  232 

gall-.     See  Cholelithiasis. 

in  kidney.     See  Nephrolithiasis. 

pyonephrosis  with,  242 

renal.     See  Nephrolithiasis. 

in  ureter,  264,  268 

cause  of  left  iliac  pain,  276 
of  right  hypochondriac  pain,  204 
iliac  pain,  259 
Strabismus,  68 
Strain,  acute  foot,  372 

back,  96 

eye-,  cause  of  headache,  33  42,  67 

muscular,  119 

sacro-iliac,  96,  97,  395 
Strangulated  ovarian  cyst,  283 
Streptococcus  bronchopneumonia,  587 

meningitis,  121 

sepsis,  308,  449 
Stricture,  intestinal,  174 
Subacromial  bursitis,  330,  t,t,t,,  335,  336,  338 
cause  of  brachial  pain,  325 


Subdiaphragmatic  abscess,   135,   229,  318, 

475 
cause    of    right    hypochondriac    pain, 
204 
Subnitrate  of  bismuth  poisoning,  228 
Sudden  death  in  cardiac  cases,  496 
Suggestibility,  hysteric,  507 
Suppurative  nephritis,  735 
Surgical  kidney,  112 
Symptom,  presenting,  17 
Symptoms  associated  with  jaundice.  718 

and  their  interpretation,  29 
Syncope  cause  of  coma,  487 
Syphilis,  43,  45,  54,  73,  75,  77.   118,   134, 
139,  154,  179,  188,  213,  214,  216,  234, 
246,  338,  355,  370,  382,  386,  389,  385, 
407,  413,  419,  422,  447,  453,  471,  497, 
504,  529,  549,  551,  625,  737 
cause  of  long  fever,  403 
cerebral,  57 
cerebrospinal,  391 
hepatic,  186,  196,  220,  725.  727 
of  liver.     See  Syphilis,  hepatic. 
visceral,  477 

with  stenosis  of  a  bronchus.  586 
Syphilitic  adenitis,  281 
disease  of  joints,  365 

of  lung,  602 
gumma,  hepatic,  156 
headache,  43 
heart  and  aorta,  296 
orchitis,  172 
periostitis,  41,  397,  398 
cause  of  headache,  33 

of  pain  in  legs  and  feet,  351 

Tabes  dorsalis,  132,  161,  177,  182.  igS,  243, 

257,  -'70,  364-  387,  51Q.  537-  557 
cause  of  pain  in  legs  and  feet,  351 

of  paralysis,  533 

of  vomiting,  609 
with  gastric  crises,  128.  166,  630,  642, 

651 
mesenterica,  264,  358,  369 
cause  of  epigastric  pain.  155 
of  general  abdominal  pain,  120 
peritonitis  cause  of  e[)igaslric  pain,  155 
Tachycardia,  paroxysmal,  61,  62 
Tapeworm,  164 
Tea-poisoning,  734 
Teething,  515 

Temperament,  its  influence  on  the  reaction 
against  infections,  466 


INDEX 


763 


Tenosynovitis   cause  of  pain   in   legs   and 

feet,  351 
Terminal  infection,  353 
Tertian  malaria.     See  Malaria,  tertian. 
Testis,  sarcoma  of,  with  metastases,  171 
Tests  to  make  in  puzzling  cases  of  headache, 

38 
Tetanus,  124 
Thickening,  chronic  pleural,  244 

pleural,  64 
Thomas,  H.  M.,  32 
Thoracic  aneurysm,  315,  341 

pain,  26 
Throat,  disease  of,  317 
Throbbing  pain,  26 
Thrombophlebitis,  336 
Thrombosis,  infectious,  332 

pelvic,  367 

peripheral,  367 

septic,  of  lateral  sinus  and  jugular  vein, 
410 
Thyroid,  simple  adenoma  of,  49 
Time  of  day,  relation  of  pain  to,  27 
Tinea  versicolor,  226 
Tonsillitis,  48,  91,  291,  309,  393,  522 

cause  of  cough,  577 
of  short  fever,  404 
"  Toqiid  liver,"  35 
To.xemia  and  pregnancy  cause  of  vomiting, 

609 
Trauma,  254 

headache  due  to,  46 
Traumatic  neurosis,  324,  335,  631,  738 

pneumonia,  596 
Trichiniasis,  66,  t,},2,  732 
Tricuspid  regurgitation,  504 
Trigeminal    neuralgia    cause    of    headache, 

33,  35 
Tubal  absicss,  263 
Tube,  purulent  infection  of,  563 

tul)crculosis  of  right,  268 
Tuberculosis,  42,  48,  76,  269,  335,  355,  376, 
382,  383,  385,  390,  412,  410.  421,  431, 
453.  457^  460,  482,  537,  545.  561.  562, 
583.  588,  591,  502,  603,  625.  636,  640, 
646.  ()47,  653,  692,  740,  742 

abdominal,  2^4 

acute,  505 

of  bladder,  280,  669,  670,  680 

of  bones,  346 

cause  of  long  fever,  403 

of  pain  in  lesis  and  feet,  351 

of  cecal  region,  261 


Tuberculosis,  costal,  320 
general,  358,  369 

genito-urinary.  669,  675,  732 

glandular,  338,  471 

of  hip,  369 

of  humerus,  333,  336 

of  kidney.     See  Kidney  tuberculosis. 

of  mesenteric  gland,  357,  427 

miliary,  56,  74,  238,  304,  454,  600,  692 

obsolete,  of  spleen,  49 

pericecal,  146,  233,  258,  261,  426 

peritoneal.     See  Tuberculous  peritonitis. 

pulmonary.     See  PlUhisis. 

renal.     See  Kidney,  tuberculous. 

spinal,  86,  91,  106-108,  115,  117,  120.  136, 

184,  342,  568 
cause  of  general  abdominal  i)ain,  129 

of  lumbar  pain,  81 
of  tube,  268 

vertebral.     Sec  Tuberculosis,  spinal. 
with  abscess,  338 
Tuberculous  colitis,  146 
empyema,  545,  701 
enteritis,  256 
epididymitis,  115 
kidney.     See  Kidney,  tuberculous. 
meningitis,  53,  56,  57,  75,  158,  643 
osteitis,  384 
osteomyelitis,  333,  335,  340.  383 

of  rib,  320 
peritonitis,  134,  142,  156,  158.  172,  174, 

188,  197,  247,  315.  417.  427.  456,  480, 

55 1'  564-  5'''0 

cause  of  general  abdoniinal  pain.  129 
pleurisy,  424,  475 
pneumothorax,  87,  298 
pus  kidney,  310 
saliMngitis,  655 
Tumor,  327,  337,  66q 
abdominal,  115,  134 

cause  of  general  abdominal  pain,  120 
of  bladder  cause  of  hematuria,  666 
brain,  55,  f)i,    70,  75,    77,  423,  496,  510, 
517,  523,  528.  C)i5.  ()4o.  642,  644,  737 

cause  of  coma.  487 
of  headache,  t,t,,  46 
cerebral.     See  Tumor,  brain. 
tiljroid,  of  uterus,  173,  263 
gastric,  1 15 
gummatous,  345 
intrathoracic,  33  6 
of  kidney.     Sec   Tumor,  rcu-il. 
of  li\er,  j:o 


764 


INDEX 


Tumor,  mediastinal,  328,  347 
cause  of  brachial  pain,  325 

ovarian,  260 

renal,  272,  675 

cause  of  hematuria,  666 
of  lumbar  pain,  81 

retroperitoneal,  221 

cause  of  lumbar  pain,  81 

of  retroperitoneal  glands,  196 

of  spleen,  248 

stomach.     See  Gastric  tumor. 
Types  and  cause  of  hematuria,  667 
of  jaundice,  717 

of  pain,  26 
Typhoid,  48.  52,  56.  57,  65.  72,  75,  77,  85, 
91,  95,  107,  122,  135,  137,  294,  301, 
303,  359,  402,  409,  411,  413,  423,  427, 
429,  431,  435,  442,  467,  478,  482,  538, 
542,  564,  566,  601,  634,  644,  653 

abortive,  444 

afebrile,  423 

brief,  420 

cause  of  long  fever,  403 

chills  occurring  in.  480 

cholecystitis,  210.  238 

diarrhea  and  tenderness  due  to  fecal  im- 
paction in,  424 

meningismus  complicating,  122 

onset  cause  of  chills,  460 

with  relapse,  418 
Typhoidal  spondylitis,  115 

Ulcer  of  bowel,  86 
chronic,  640 

peptic,  170,  174.  175,  182.  185,  190,  192, 
194,    198,   200,   223,    228.   246.   252, 
617,  620,  622,  630 
cause  of  epigastric  pain,  155 

of  vomiting,  609 
of  duodenum,  131,  140,  159,  163,  166, 

167,  169,  176,  212,  234 
of  stomach,  86,  157,  187,  191,  616,  637, 
648,  682,  737 
perforated  gastric,  89,  177,  277 
Ulcerative  endocarditis,  92,  420 
Unknown  cause  of  hematuria,  678,  682 
infection,  54,  95,  293,  443 
origin,  cystitis  of,  675 
headache  of,  68 
Unlocalized  and  widespread  infections,  207 
Unresolved  pneumonia,  64 

diagnoses  made  at  the  Massachusetts 
General  Hospital,  437 


Uremia,  31,  55,  61,  70,  200,  509,  513,  528, 
645,  660 
cause  of  coma,  487 
of  convulsions,  500 
of  vomiting,  609 
Uremic  headache,  49 
Ureter,  stone  in,  264,  268 

cause  of  right  hypochondriac  pain,  204 
Urethritis,  343,  388,  391 
Urinary  infection,  104,  564 
Urticaria,  internal,  605 
Urticarial  fever,  447 
lesions,  73 
discussed  by  Osier,  448 
Uterine  fibroid,  173,  263 
group  of  backaches,  79 
Uterus,  carcinoma  of,  381 
fibroid  tumor  of,  173,  263 
fibromyoma  of,  283 

prolapsed,  retroverted,  incarcerated,  preg- 
nant, 122 

Valves,  fibrous  endocarditis  of  mitral  and 

aortic,  215 
Valvular  disease,  chronic,  495 

Varicose  veins,  282 

cause  of  pain  in  legs  and  feet,  351 
Vascular  crisis,  31,  181,  387,  432,  510,  511, 
521 

hyperemia,  26 
Vasomotor  headaches,  26,  37 
\'ertebral  tuberculosis.       See   Tuberculosis, 

spinal. 
\'icarious  menstruation,  317 
Visceral  syphilis,  477 
Volvulus,  151 
\'omiting,  608 

important  factors  in  production  of,  611 

of  pregnancy,  654 
\'ulnerability  of  all  differential  diagnosis,  19 

Walton",  G.  L..  32 
Weak  heart,  305 
Weakness,  534 

causes  of,  535 
Weather  and  season,  relation  to  pain,  28 
"  Wet  brain,"  77 

Wides!)read  and  unlocalized  infections,  207 
"  Writer's  cramp,"'  524 

Yellow  atrophy  of  liver,  acute,  727 

Zoster,  herpes,  86,  93,  360 


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a  book  of  this  size.      Particular  consideration  is  given  the  mouth  and  teeth. 

Pennsylvaoiia  Medical  Journal 

"  It  is  arranged  in  such  a  manner  as  to  be  easy  of  access  and  comprehension.  To  any 
contemplating  the  study  of  histology  and  urganograjihy  we  would  commend  this  work." 


SAUNDERS'    BOOKS   ON 


GET  A  •  THE  NEW 

THE  BEST    .  /\  in  6  r  1  C  Si  H  standard 

Illustrated   Dictionary 

New  (6th)  Edition,  Entirely  Reset 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches ;  with  over  lOO  new  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "  The 
American  Pocket  Medical  Dictionary."  Large  octavo,  986  pages, 
bound  in  full  flexible  leather.  Price,  $4.50  net ;  with  thumb  index, 
^5.00  net. 

IT  DEFINES  ALL  THE  NEW  WORDS— IT  IS  UP  TO  DATE 

Dorland's  Dictionary  defines  hundreds  of  the  newest  terms  not  defined  in  any 
other  dictionary — bar  none.  These  new  terms  are  hve,  active  words,  taken 
right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.  It  makes  a  feature  of 
the  derivation  or  etymology  of  the  words.  In  some  dictionaries  the  etymology 
occupies  only  a  secondary  place,  in  many  cases  no  derivation  being  given  at  all. 
In  "  Borland,"  practically  every  word  is  given  its  derivation. 

In   "  Borland "   every  word  has  a  separate  paragraph,   thus  making  it  easy  to 

find  a  word  quickly. 

The   tables   of   arteries,    muscles,    nerves,    veins    etc.,    are    of  the    greatest    help 

in  assembling   anatomic   facts.      In   them   are   classified   for   quick   study   all   the 

necessary  information  about  the  various  structures. 

In    "Borland"    every    word    is    given    its    definition — a    definition    that    defines 

in  the  fewest  possible  words.      In   some  dictionaries  hundreds  of  words  are  not 

defined  at  all,  referring  the  reader  to  some  other  source  for  the  information  he 

wants  at  once. 

Howard  A.  Kelly,   M.  D.,   Johns  Hopkins   University,   Baltimore 

"  Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it," 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.).   Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


PATHOLOGY. 


Stengers 
Text-Book  of  Pathology 


The    New  (5th)   Edition 


A  Text-Book  of  Pathology.  By  Alfred  Stengel,  M.  D.,  Professor 
of  Medicine  in  the  University  of  Pennsylvania.  Octavo  volume  of  979 
pages,  with  400  text-illustrations,  many  in  colors,  and  7  full-page 
colored  plates.     Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.z^o  net. 

WITH  400  TEXT-CUTS.  MANY  IN  COLORS,  AND  7  COLORED  PLATES 

In  this  work  the  practical  application  of  pathologic  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of  the 
book,  an  effort  has  been  made  to  present  the  subject  from  the  point  of  view  of  the 
clinician.  In  the  second  part  of  the  work  the  pathology  of  individual  organs  and 
tissues  is  treated  systematically  and  quite  fully  under  subheadings  that  clearly 
indicate  the  subject-matter  to  be  found  on  each  page.  In  this  edition  the  section 
dealing  with  C.eneral  I'athology'has  been  must  extensively  revised,  several  of  the 
important  chapters  having  been  practically  rewritten.  A  very  useful  addition 
is  an  Appendix  treating  of  th'  technic  of  pathologic  methods,  giving  briefly  the 
most  important  methods  at  present  in  use  for  the  study  of  pathology,  including, 
however,  only  those  methods  capable  of  giving  satisfactory  results.  The  book 
will  be  found  to  maintain  fully  its  popularity. 


PERSONAL  AND   PRESS  OPINIONS 


William  H.  Welch.  M.  D.. 

Professor  of  Patholcgy,  Johns  Hopkins   University.   Baltimore,  Md. 

"  I  consider  the  work  abreast  of  motiern  patholo,s:^y,  and  useful  to  both  students  and  jiracti- 
tionors.  It  presents  in  a  concise  and  well-eonsidereii  form  tlie  essential  facts  of  [general  and 
special  pathologic  anatomy,  with  more  than  usual  emphasis  upon  pathologic  physiology." 

Ludvi^  Hektoen,  M.  D., 

Professor  of  Patholox'y.  Rush  AfeJio.i/  Co//,-!re.   Chicat^o. 

"  I  regard  it  as  the  most  serviceable  text-book  for  students  on  this  subject  yet  written  by  an 
American  author." 

The  Lancet,  London 

"'I  his  vohuTie  is  intended  to  present  the  subject  of  patliologv  in  as  practical  a  form  as  pos- 
sil)le,  and  mure  especially  from  the  point  of  view  i>f  tht'  ■rlinic;ii  5\it!i<>:o<,MSt.'  Thi'se  subjects 
have  been  faithftdly  carried  out,  and  avair.able  t'-xt-book  i-  the  result.  We  can  most  fa\orabiy 
recommend  it  to  our  readers  as  a  thoroughly  pr.ictical  work  on  clinical  p.ithoiogy." 


SAUNDERS'    BOOKS   ON 


Mallory  and  Wright's 
Pathologic  Technique 

New  (5th)    Edition,  Revised 


Pathologic  Technique.  A  Practical  Manual  for  Workers  in  Patho- 
logic Histology,  including  Directions  for  the  Performance  of  Autopsies 
and  for  Clinical  Diagnosis  by  Laboratory  Methods.  By  Frank  B. 
Mallory,  M.  D.,  Associate  Professor  of  Pathology,  Harvard  Univer- 
sity ;  and  James  H.  Wright,  M.  D.,  Director  of  the  Pathologic  Labora- 
tory, Massachusetts  General  Hospital.  Octavo  of  500  pages,  with  152 
illustrations.     Cloth,  $3.00  net. 

WITH  CHAPTERS  ON  POST-MORTEM  TECHNIQUE  AND  AUTOPSIES 

In  revising  the  book  for  the  new  edition  the  authors  have  kept  in  view  the 
needs  of  the  laboratory  worker,  whether  student,  practitioner,  or  pathologist,  for 
a  practical  manual  of  histologic  and  bacteriolog.ic  methods  in  the  study  of  patho- 
logic material.  Many  parts  have  been  rewritten,  many  new  methods  have  been 
added,  and  the  number  of  illustrations  has  been  considerably  increased.  Among 
the  new  matter  are  the  following  :  Smith's  staining  method  for  encapsulated 
bacteria  ;  the  antiformin  method  for  detection  and  cultivation  of  tubercle  bacilli  ; 
Musgrave's  and  Clegg's  method  for  the  cultivation  of  amelxe  ;  Wright's  method 
for  staining  myelin  sheaths  in  frozen  sections  ;  Ghoreyeb's  method  for  spirochetes  ; 
Alzheimer's  method  for  cytologic  examination  of  cerebrospinal  fluid  ;  Giemsa's 
new  method  for  protozoa  and  bacteria  in  sections,  and  the  Wassermann-Noguchi 
tests  for  syphilis. 


PERSONAL  AND   PRESS  OPINIONS 


Wm.  H.  Welch.  M.  D.. 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that  I 
find  it  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information  and  well 
up  to  date." 

Boston  Medical  and  Surgical  Journal 

"  This  manual,  since  its  first  appearance,  has  been  recognized  as  the  standard  guide  m  patho- 
logical technique,  and  has  beconn;  well-nigh  indispensaijle  to  the  lal)oratory  worker." 

Journal  of  the  American  Medical  Association 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  phvsician  who  licpes  to  keep  pace  with  the  great  advances  made  in  pathology." 


EMBRYOLOGY. 


Heisler's 
Text-Book  qf  Embryology 

Third  Edition 


A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia, 
Octavo  volume  of  435  pages,  with  212  illustrations,  32  of  them  in 
colors.     Cloth,  ^3.00  net. 

WITH    212     ILLUSTRATIONS.     32     IN     COLORS 

The  fact  of  embryology  having  acquired  in  recent  years  such  great  interest 
in  connection  with  the  teaching  and  with  the  proper  comprehension  of  human 
anatomy,  it  is  of  first  importance  to  the  student  of  medicine  that  a  concise  and 
yet  sufficiently  full  text-book  upon  the  subject  be  available.  This  new  edition 
represents  all  the  latest  advances  recently  made  in  the  science  of  embryology. 
Many  portions  have  been  entirely  rewritten,  and  a  great  deal  of  new  and  impor- 
tant matter  added.  A  number  of  new  illustrations  have  also  been  introduced  and 
these  will  prove  very  valuable.  The  previous  editions  of  this  work  filled  a  gap 
most  admirably,  and  this  new  edition  will  undoubtedly  maintain  the  reputation 
already  won.      Heisler's  Embryology  has  become  a  standard  work. 


PERSONAL  AND   PRESS  OPINIONS 


G.  Carl  Huber.  M.D., 

Frojessor  of  Kmbry.^lci^y  ,:f  the   Wistar  Iintiiiitc,  University  of  Ponnylvania. 
"  I  find  the   second  edition    of  'A  Text-Book  of  Embryology'  by  Dr.  Heisler  .in  improve- 
ment on   the   first.     The   fiLTures   adde<l    increase   greatly  the  value  of  the  wuik.     I   am  again 
recotnnuMuling   it   to  our  students." 

William  Wathen,  M.  D., 

Professor  of  Obstetrics.  Abdominal  Surt^ory.  and  C,ynecolo<:y ,  and  Doan .  Kontucky  School  of 

Aledicine,  Louis'nlle .  h'v. 
"  It   is  systematic,  scientific,  full   of  simjilicity.  and   just   such  a  work    as   a    medical  student 
will   be  al)Ie   to  com[>rchend." 

Birmingham  Medical  Review,  England 

"We  can  most  contidrntly  recommend  Dr.  lleishr'.';  book  to  tlie  student  of  bio'.ogv  or 
medicine  for  his  careful  study,  if  his  aim  be  to  acciuiie  a  sound  and  practical  acquaintance  with 
the  '  ubjrct  of  (.'mbrv"  logy." 


lo  SAUNDERS'    BOOKS   ON 

Wells*  Chemical  Pathology 


Chemical  Pathology. — Being  a  Discussion  of  General  Pathology 
from  the  Standpoint  of  the  Chemical  Processes  Involved.  By  H. 
Gideon  Wells,  Ph.  D.,  M.  D.,  Assistant  Professor  of  Pathology  in  the 
University  of  Chicago.     Octavo  of  549  pages.     Cloth,  ^3.25  net. 

A  PRACTICAL   BOOK 

Dr.  Wells'  work  is  written  for  the  physician,  for  those  engaged  in  research  in 
pathology  and  physiologic  chemistry,  and  for  the  medical  student.  In  the  intro- 
ductory chapter  are  discussed  the  chemistry  and  physics  of  the  animal  cell,  giving 
the  essential  facts  of  ionization,  diffusion,  osmotic  pressure,  etc.,  and  the  relation 
of  these  facts  to  cellular  activities.  Special  chapters  are  devoted  to  Diabetes  and 
to  Uric-acid  Metabolism  and  Gout. 

Wm.   H.  Welch,  M.  D. 

Professor  of  Pathology,  Johns  Hopkins  University. 

"The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my    students." 

Lusk*s 

Elements  of  Nutrition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk,  Ph.  D., 
Professor  of  Physiology  at  Cornell  Medical  School.  Octavo  volume 
of  302  pages.     Cloth,  ;^3.oo  net. 

THE  NEW  (2d)  EDITION— TRANSLATED  INTO  GERMAN 

Prof.  Lusk  presents  the  scientific  foundations  upon  which  rests  our  knowledge 
of  nutrition  and  metabolism,  both  in  health  and  in  disease.  There  are  special 
chapters  on  the  metabolism  of  diabetes  and  fever,  and  on  purin  metabolism. 
The  work  will  also  prove  valuable  to  students  of  animal  dietetics  at  agricultural 
stations. 

Lewellys  F.  Barker,  M.  D, 

Professor  of  the  Principles  and  Practice  of  Medirine,  Johns  Hopkins  University. 
"  I  shall  recommend  it  highly  to  my  students.     It  is  a  comfort  to  have  such  a  discussion 
of  the  subject  in  English." 


HISTOLOGY. 


Bohm,  Davidoff,  anb 
Ruber's  Histolo^ 


A  Text-Book  of  Human  Histology.  Including  Microscopic  Tech- 
nic.  By  Dr.  A.  A.  Bohm  and  Dr.  M.  von  Davidoff,  of  Munich,  and 
G.  Garl  Huber,  M.D.,  Professor  of  Embryology  at  the  Wistar  Insti- 
tute, University  of  Pennsylvania.  Handsome  octavo  of  528  pages,  with 
361  beautiful  original  illustrations.     Flexible  cloth,  ^3.50  net. 

THE    NEW    (2d)    EDITION,    ENLARGED 

The  work  of  Drs.  Ilohm  and  Davidoff  is  well  known  in  the  German' edition, 
and  has  been  considered  one  of  the  most  practically  useful  books  on  the  subject 
of  Human  Histology.  This  second  edition  has  been  in  great  part  rewritten  and 
very  much  enlarged  by  Dr.  Huber,  who  has  also  added  over  one  hundred  origi- 
nal illustrations.  Dr.  Huber' s  extensive  additions  have  rendered  the  work  the 
most  complete  students'  text-book  on  Histology  in  existence. 

Boston  Medical  and  Surgical  Journal 

"  Is  unquestionably  a  text-book  of  the  first  rank,  having  been  carefully  written  by  thorough 
masters  of  the  subject,  and  in  certain  directions  it  is  much  superior  to  anv  other  histological 
manual." 


DrewV 

Invertebrate  Zoology 

A  Laboratory  Manual   of    Invertebrate  Zoology.     By    Oilman    A 

Drew,  Ph.  I).,  Professor  of  r>iology  at  the  University  of  Maine.  With  the 
aid  of  Members  of  the  Zo()logi(al  Staff  of  Instructors  of  the  Marine  f5iolog- 
ical  I^iboratory,  Woods  Holl,  Mass.      i2mo  of  200  pages.     Cloth,  5;i.25  net. 

A    LABORATORY    WORK 

The  subject  is  presented  in  a  logical  way,  and  the  type  method  of  study  has 
been  followed,  as  this  method  has  been  the  prevailing  one  for  many  years. 

Prof.  Allison  A.  Smyth,  Jr.,  Virginia  Polytechnic  Institute 

"  I  tliink  It  is  th''  hi'-.t  i  ilxir.Uory  manual   ol   /"■i;,,r.v    1    have   yet   seen.     The   large  number 
of  forms  dealt  with  m.ikes  the  work  applical)lc  to  almost  any  iocaiity." 


12  SAUNDERS    BOOKS    ON 


Norris*   Cardiac   Patholo^ 

studies  in  Cardiac  Pathology.  By  George  W.  Norris,  M.D., 
Associate  in  Medicine  at  the  University  of  Pennsylvania.  Large  octavo 
of  235  pages,  with  85  superb  illustrations.     Cloth,  ^5.00  net. 

SUPERB    ILLUSTRATIONS 

The  wide  interest  being  manifested  in  heart  lesions  makes  this  book  particu- 
larly opportune.  The  illustrations  are  superb  and  are  faithful  reproductions  of 
the  specimens  photographed.  Each  illustration  is  accompanied  by  a  detailed 
description  ;  besides,  there  is  ample  letter  press  supplementing  the  pictures. 
Considerable  matter  of  a  diagnostic  and  therapeutic  nature  has  been  interwoven. 

Boston  Medical  and  Surgical  Journal 

"  The  illustrations  are  arranged  in  such  a  way  as  to  illustrate  all  the  common  and  many  of 
the  rare  cardiac  lesions,  and  the  accompanying  descriptive  text  constitutes  a  fairly  continuous 
didactic  treatise." 


McConnell's  Pathology 

A  Manual  of  Pathology.  By  Guthrie  McConnell,M.D.,  Professor 
of  Bacteriology  and  Pathology  at  Temple  University,  Philadelphia. 
i2mo  of  523  pages,  with  170  illustrations.     Flexible  leather,  $2.50  net. 

NEW  (2d)  EDITION 
Dr.  McConnell  has   discussed   his  subject  with   a   clearness  and  precision  of 
style  that  make  the  work  of  great  assistance  to  both  student  and  practitioner. 
The  illustrations  have  been  introduced  for  their  practical  value. 

New  York  State  Journal  of  Medicine 

"  The  book  treats  the  subject  of  pathology  with  a  thoroughness  lacking  in  many  works  of 
greater  pretension.  The  illustrations — many  ef  them  original — are  profuse  and  of  exceptional 
excellence."  v 


Hektoen  and  Riesman's  Patholo^ 

American  Text-Book  of  Pathology.  Edited  by  Ludvig  Hek- 
toen, M.D.,  Professor  of  Pathology,  Rush  Medical  College,  Chi- 
cago; and  David  Riesman,  M.D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  of  1245  P^g^s,  443  illustra- 
tions, 66  in  colors.     Cloth,  $7.50  net;   Half  Morocco,  ;$9.oo  net. 


HISTOLOGY.  13 


Dtirck  anb  Hektoen*s 

Special    P&thologlc   Histolo^ 

Atlas  and  Epitome  of  Special  Pathologic  Histology.     By  Dr.  H. 

DiJRCK,  of  Munich.  Edited,  with  additions,  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  two  parts. 
Part  I. — Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts.  120 
colored  figures  on  62  plates,  and  158  pages  of  text.  Part  II. — Liver, 
Urinary  and  Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and 
Bones.  123  colored  figures  on  60  plates,  and  192  pages  of  text.  Per 
part:  Cloth,  $3.00  net.     ///  Saunders'  Hand-Atlas  Scries. 

The  great  value  of  these  plates  is  that  they  represent  in  the  exact  colors  the  effect 
of  the  stains,  which  is  of  such  great  importance  for  the  differentiation  of  tissue. 
The  text  portion  of  the  book  is  admirable,  and,  while  brief,  it  is  entirely  satisfac- 
tory in  that  the  leading  facts  are  stated,  and  so  stated  that  the  reader  feels  he  has 
grasped  the  subject  extensively. 

William  H.  Welch,  M.  D., 

Professor  of  Patholo^^y,  Johns  Hopkins  University,  Baltimore. 

"I  consider  Diirck's  'Atlas  of  Special  Pathologic  Histology,' edited  by  Hektoen,  a  very 
useful  book  for  students  and  others.     The  plates  are  admirable." 

Sobotta  and  Huberts 
Human  Ilistolog(y 

Atlas  and  Epitome  of  Human  Histology,  l^y  Pkivatdocext  Dr. 
J.  SoHOTTA,  of  Wiirzburg.  Edited,  witli  additions,  by  G.  Carl  Hl'Ber, 
M.  D.,  Professor  of  Histology  and  Embrj'ology  in  the  University  of 
Michigan,  Ann  Arbor.  With  214  colored  figures  on  80  plates,  68 
text-illustrations,  and  248  pages  of  text.  Cloth,  S4.50  net.  /// 
Saunders'  Hatid-Atlas  Series. 

INCLUDING    MICROSCOPIC   ANATOMY 

The  work  combines  an  alnmdanre  of  wcll-rhosen  and  most  accurate  illustra- 
tions, with  ;i  concise  text,  and  in  such  a  manner  as  to  make  it  Iioth  atlas  and  text- 
book. The  i;reat  majority  of  the  illustrations  were  made  from  .sections  prepare<l 
from  human  tissues,  and  always  from  fresh  and  in  every  respert  miri'.ial  specimens. 
'i'he  colored  lithoL:raphic  plates  ha\e  l)een  produced  with  the  aid  of  (u-er  thirty  colors. 

Boston  Medical  and  Surgical  Journal 

"  In  color  and  proportion  they  arc  cli.xracterized  by  gr.itifv  itiL:  accuracy  and  lithographic 
bcautv." 


14  SAUNDERS'    BOOKS   ON 

Bosanquet  on  Spirochaetes 

Spirochaetes :  A  Review  of  Recent  Work,  with  Some  Original  Ob- 
servations. By  W.  Cecil  Bosanquet,  M.D.,  Fellow  of  the  Royal  Col- 
lege of  Physicians,  London.    Octavo  of  1 52  pages,  illustrated.  ;^2.50  net. 

ILLUSTRATED 

This  is  a  complete  and  authoritative  monograph  on  the  spirochaetes,  giving 
morphology,  pathogenesis,  classification,  staining,  etc.  Tseudospirochastes  are 
also  considered,  and  the  entire  text  well  illustrated.  The  high  standing  of  Dr. 
Bosanquet  in  this  field  of  study  makes  this  new  work  particularly  valuable. 


Levy  and  Klemperer*s 
Clinical  Bacteriolo^ 

The  Elements  of  Clinical  Bacteriology.  By  Drs.  Ernst  Levy  and 
Felix  Klemperer,  of  the  University  of  Strasburg.  Translated  and 
edited  by  Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  volume  of  440  pages,  fully  illustrated. 
Cloth,  ^2.50  net. 

S.  Solis-Cohen,  M.  D., 

Professor  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

"  I  consider  it  an  excellent  book.     I  have  recommended  it  in  speaking  to  my  students." 


Lehmann,  Neumann,  and 
Weaver's  Bacteriology 

Atlas  and  Epitome  of  Bacteriology :  including  a  Text-Book  of 
Special  Bactkriologic  Diagnosis.  By  Prof.  Dr.  K.  B.  Lehmann 
and  Dr.  R.  O.  Neumann,  of  Wurzburg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  G.  H.  Weaver, 
M.  D.,  Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical 
College,  Chicago.  In  two  parts.  Part  1.^632  colored  figures  on  69 
lithographic  plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  $2.50  net.     /;/  Sannders   Idaiid-Atlas  Series. 


PATHOLOGY,    BACTERIOLOGY,    AND   PATHOLOG\.  15 

Eyre's   Bacteriologic   Technique 

The  Elements  of  Bacteriologic  Technique.  A  Laboratory 
Guide  for  the  Medical,  Dental,  and  Technical  Student.  By  J,  W. 
H.  Eyre,  M.  D.,  F.  R.  S.  Edin.,  Lecturer  on  Bacteriology  at  the 
Medical  and  Dental  Schools,  London,  Octavo  of  375  pages,  with 
170  illustrations.     Cloth,  $2.50  net. 

American  Text-Book  of  Physiolo^  second  Edition 

American  Text-Book  of  Physiology.  In  two  Yolumes.  Edited  by 
William  H.  Howell,  Ph.  D.,  M.D.,  Professor  of  Physiology  in  the  Johns 
Hopkins  University,  Baltimore,  Md.  Two  royal  octavos  of  about  600 
pages  each,  illustrated.  Per  volume:  Cloth,  $3.00  net;  Half  Morocco, 
$4.25  net. 

"  The  work  will  stand  as  a  work  of  reference  on  physiology.  To  him  who  desires  to  know 
the  status  of  modern  physiology,  who  expects  to  obtain  suggestions  as  to  further  physio- 
logic inquiry,  we  know  of  none  in  English  which  so  eminently  meets  such  a  demand." — 
The  Medical  News. 

Warren's  Pathology  and  Therapeutics        second  Edition 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Med- 
ical School.  Octavo,  873  pages,  136  relief  and  lithographic  illustrations, 
33  in  colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis 
and  a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net; 
Half  Morocco,  ^6.50  net. 

Gorham's  Bacteriolo^ 

A  Laboratory  Course  in  Bacteriology.  For  the  Use  of  Medical, 
Agricultural,  and  Industrial  Students.  By  Frederic  P.  Gorham,  A.  M., 
Associate  Professor  of  Biology  in  Brown  University,  Providence,  R.  I., 
etc.      i2mo  of  192  pages,  with  97  illustrations.      Cloth,  $1.25  net. 

"  One  of  tlie  best  students'  laboratory  guides  to  the  study  of  bacteriology  on  the  mar- 
ket. .  .  .  The  technic  is  thoroughly  modern  and  amply  sufficient  for  all  practical  pur- 
poses. " — American  Journal  of  the  Medical  Sciences. 

Raymond's  Physiolo^  New  (3d)  Edition 

Human  Phvsiolo(;y.  BvJosi-.ph  H.  Raymond,  A.  M.,  M.  D.,  Pro- 
fessor of  Physiology  and  Hygiene,  long  Island  College  Hos])ital,  New 
York.      Octavo  of  685  pages,  with  444  illustrations.      Cloth,  .^3.50  net. 

"  The  book  is  well  gotten  up  niul  well  pri;ite<l,  :in(l  niav  be  regarded  as  a  trustwcrthv 
pfuide  for  the  sttident  an<l  a  useful  work  of  reference  for  the  genera;  practitioner.  The 
illustrations  are  numerous  and  arc  well  executed.  " — Tht  Lancet,  London. 


I6  BACTERIOLOGY,    PHYSIOLOGY,    AND   HISTOLOGY, 

Ball's    Bacteriology  sixth  Edition.  Revited 

Essentials  of  Bacteriology  :  being  a  concise  and  systematic  intro- 
duction to  the  Study  of  Micro-organisms.  By  M.  "V.  Ball,  M.  D.,  Late 
Bacteriologist  to  St.  Agnes'  Hospital,  Philadelphia.  i2mo  of  289  pages, 
with  135  illustrations,  some  in  colors.  Cloth,  ^i.oo  net.  In  Saunders' 
Question-  Compend  Series. 

"  The  technic  with  regard  to  media,  staining,  mounting,  and  the  like  is  culled  from  the 
latest  authoritative  works." — T/ie  Medical  Times,  New  York. 

Budgett'S    Physiology  New  Od)  Edition 

Essentials  of  Physiology.  Prepared  especially  for  Students  of  Medi- 
cine, and  arranged  with  questions  following  each  chapter.  By  Sidney 
P.  Budgett,  M.  D.,  formerly  Professor  of  Physiology,  Washington  Uni- 
versity, St.  Louis.  Revised  by  Havan  Emerson,  M.  D.,  Demonstrator 
of  Physiology,  Columbia  University.  i2mo  volume  of  250  pages,  illus- 
trated.    Cloth,  $1.00  net.     Saunders' Question- Compend  Series. 

"He  has  an  excellent  conception  of  his  subject.  .  .  It  is  one  of  the  most  satisfactory 
books  of  this  class"  —  University  of  Pennsylvania  Medical  Bulletin. 

Leroy*s  Histology  New  f4th)  Edition 

Essentials  of  Histology.     By  Louis  Leroy,  M.  D.,  Professor  of 

Histology  and  Pathology,  Vanderbilt  L^^niversity,  Nashville,  Tennessee. 

i2mo,  263  pages,  with  92  original  illustrations.     Cloth,  $1.00  net.     In 

SauJiders'  Question-  Co?npend  Series. 

"  The  work  in  its  present  form  stands  as  a  model  of  what  a  student's  aid  should  be  ;  and 
we  unhesitatingly  say  that  the  practitioner  as  well  would  find  a  glance  through  the  book 
of  lasting  benefit." — TAe  Medical  World,  Philadelphia. 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  ]\L  D.,  Assistant  Professor  or'  Materia  Medica  and  Therapeutics, 
and  Walter  A.  Wells,  M.D.,  Demonstrator  of  Larvngolopv,  Georgetown 
University,  Washington,  D.  C.  121110,  534  pages.  Flexible  leather, 
$2.50  net;   thumb  indexed,  S3. 00  net. 

American  Pocket  Dictionary  New  7th)  Edition 

Dorland's  Pocket  Medical  Dictionary.  Edited  oy  W.  A.  New- 
man Dorland,  M.  D.,  Editor  "American  Illustrated  ^^ledical  Dic- 
tionary." Containing  the  jjronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  64  extensive  tables. 
610  pages.  Flexible  leather,  with  gold  edges.  $1.00  net;  with  patent 
thumb  index,  51.25  net. 

"I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  of 
the  Jefferson  Medical  College,  Philadelphia. 


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